Johnson, Mary 4 511
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
4 Name First Middle Last Sex
Mary C. Johnson Female
Date of Death Age If Veteran of U.S. Armed Forces,
= ; July 18,2018 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 329 State Route 418
Manner of Death 'XI Natural Cause Accident I 'Homicide Suicide I I Undetermined i Pending
Circumstances Investigation
AO Medical Certifier Name Title
.0 Darci Ann Gaiotti-Grubbs MD
Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
] City, Town or Village Warrensburg 5660 I it-
0 Burial Date Cemetery or Crematory
July 20,2018 Pine View Crematory
0 Entombment Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z -Removal and/or Held
Q and/or Address
Hold
Cl)
p Date Point of
gj I I Transportation Shipment
p by Common Destination
Carrier
(Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
r Permit Issued to Registration Number
.. Name of Funeral Home Alexander-Baker Funeral Home 00037
1 Address
-: 3809 Main Street,Warrensburg,NY 12885
t1 Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
El, Address
tY.
W'
Permission is hereby granted to dispose of the hum n' em ins a scr'bed above as dicated.
Date Issued 7-19-18 Registrar of Vital Statistic , in. \LJ-e t--
(si nature)3
s District Number 5660 Place Warrensburg,NYI
I H
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1110 IA Place of Disposition gwlj , l
E (address)
W
cn
cc (section) (lo number) (grave number)
0
O Name of Sexton or Person in Charge of Premises 6nnfPL S1-- 1
Z L.
� /i(please pant)
al SignatureTitle lriv4
(over)
DOH-1555(02/2004)