Loading...
Johnson, Mark C. /177 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records - Name First Middle Last Sex Mark C.Johnson Male Date of Death Age If Veteran of U.S.Armed Forces, 10/12/2020 73 Years War or Dates F_ Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 383 Cobble Creek Road,Chester Town Warren,New York 12853 p Manner of Death © Natural Cause ❑Accident Ei Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title CI Ellen Deprey PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 11 ❑Burial Date Cemetery,Crematory or Facility Name 10/15/2020 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held F- Hold Address 0 a 1-1 Date Point of co Li Transportation CI by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom l— Remains are Shipped,If Other than Above 2 Address CC W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/14/2020 Registrar of Vital Statistics Mindy Conway(ECectronica((y Signed) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition /I I(bjTa Place of Disposition R /A— I— (address) W CC (section) /f(lot number (grave number) � U/Il 0 Name of Sexton or Person in Charge of Premises (pie bseprint) w . � � farittit Signature G�J' Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01-411 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#