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Johnson, Steve McLain • 11- /172 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Steve Mc Lain Johnson Male Date of Death Age If Veteran of U.S.Armed Forces, 10/11/2020 52 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 367 Crystal Lane,Moreau Town,New York 12828 W p Manner of Death ©Natural Cause El Accident ❑Homicide ❑Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 43 ❑Burial Date Cemetery,Crematory or Facility Name 10/14/2020 Pine View Crematorium ❑Entombment' Address X❑Cremation Queensbury Town,New York ❑Donation Z Date Place Removed o ❑Removal and/or and/or Held Hold Address 0 d Date Point of co Li Transportation p by Common Shipment Carrier Destination EiDisinterment Date Cemetery Address DReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above Address Et W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/14/2020 Registrar of Vital Statistics Leeann cabe(ECectronica1Ty Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition /D Ib 1 Place of Disposition �. W ' Z�+ 4 e'ss) W CC (section) (lot number (grave number) g Name of Sexton or Person in Cha f Premises c�I (ple se rin /' W Signature Title /. ✓P141 �-- DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) a 1 all 4 Receipt Human remains of f delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#