Johnsen, Robert :, A 3S/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial -Transit Permit
Name First Middle . Last Sex M
I\0ber4 Dennis Johnsen
Date of Death Age If Veteran of U.S. Armed Forces,
0 5 I"19 i 2 0"i L1 Co 5 War or Dates 11'0 - 1 9 7- 1
Place of Death , Hospital, Institution or
City, Town or Village C1e ins F . F )-
ILI . \� S Street Address G le n S -� ��s sip; -1-<. I
WManner of Death Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined ❑Pending
o Circumstances Investigation
W Medical Certifier Name Title
- Cl G rm S c; cA rno r c rbner
Address
Death Certificate Filed District Number Register Number
City, Town or Village C -ens re, t\S ; , �� 5-1
El Burial ' Datehh// Cemetery or Crematory
❑Entombment l I 3 20 T, n�Vo e.. ) C rc r,-.‹1 f
Addressss
Cremation 2 i C a 12oc_01, a.0 o s ,r� PI
Date Place Removed
Z❑Removal and/or Held
and/or Address
Cl)
Hold
O.
Date Point of
49)1 0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to _. Registration Number
/y�
Name of Funeral Home The).3 Y-4`rw. ,��Q ll to CD 1 0 1-9
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
cr
LEI
` Permission is hereby granted to dispose of the human remains des ribe ab ve icated.
Date Issued OG pZ` �/V Registrar of Vital Statistics
f
(signature)
District Number 5-4,O/ Place 6/4,y l/, Aix
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 6)Jj f/ii Place of Disposition ,nt UL, T+ ea„,,,
2 (address)
ILI
VI
CC (section) (lot numbed.. (grave number)
SName of Sexton or Person . Charge Premises rr r e��
z (please print)
lEE Signature $1 Title C�
(over)
DOH-1555 (02/2004)