Johnson, Brenda A. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First 161,
Last Sex
Brenda AJohnson Female
Date of Death Age If Veteran of U.S
10/10/2020 65 War or Dates Place of Death Hospital,Institution or
Z City,Town or Village Warrensburg Street Address Deceased's Residence
pManner of Death ig Natural Cause n Accident ❑Homicide Suicide Undetermined Pending
W Circumstances Investigation
O Medical Certifier Name Title
\='Jl- PA-QL 84-et-(n i NO_
Address
!-<-410 v ORTatw 'A 2 (/
1
Death Certificate Filed District Number Register Number
City,Town or Village T/O Warrensburg 5660
EjBurial Date Cemetery,Crematory or Facility Name
10/15/2020 Pine View Crematory
0 Entombment Address
pCremation
Donation 21 Quaker Rd., Queensbury,NY 12804
go ID Removal Date Place Removed
- and/or and/or Held
H- Hold Address
N
0
Date Point of
(/) U Transportation Shipment
Q by Common
Carrier Destination
El Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 0037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I—. Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human rains described eras ndicated.
Date Issued tc,ilit Registrar of Vital Statistics \\; kM s y
(signatu
District Number 5660 Place T/O Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this perms u
#Date of Disposition ldllS IO Place of Disposition �...,, .•�
(address)
W
Cl)CC (section) (lot numb r (grave number)
0 Name of Sexton or Person in Cha Premises AliT • �►4td-f�/pase print)
Z trine
W Signature '> Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 044111 swie01.4115
Receipt 3'
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#