Johnson, Mary Ellen f
NEW YORK STATE DEPARTMENT OF HEALTH : ..
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Ellen Johnson Female
t"
, Date of Death Age If Veteran of U.S. Armed Forces,
._ 9
'. 04/30/2018 78 Years War or Dates
Place of DeathJ aft-, Hospital, Institution or
City, Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center
r Manner of Death m Natural Cause Accident �Homicide 0 Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
x
Address
_ 17 Madison St,Granville Village,New York 12832
:17 Death Certificate Filed District Number Register Number
a-4. City, Town or Village Granville Village 5725 18
0 Burial Date Cemetery or Crematory
05/04/2018 Pine View Crematory
-❑Entombment Address
®Cremation Queensbury Town, New York
XI
Date Place Removed
❑Removal and/or Held
and/oril Address
Hold
Date Point of
$ Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El M
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home Inc 00885
Address
01 46 Williams Street,Whitehall Village,New York 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Tir
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued 05/02/2018 Registrar of Vital Statistics Richard 2pberts('EfectronicaflySigned)
(signature)
ala District Number 5725 Place Granville Village, New York
a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition S j3(tg Place of Disposition &U..- A,
(address)
rril
4 (section) li(lot number) (grave number)
Name of Sexton or Person in Charge of Premises } ��
lease print)
-� Signature Title C
(over)
DOH-1555(02/2004)