Johnson, Dean NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dean A.Johnson Male
Er
Date of Death Age If Veteran of U.S. Armed Forces,
10/31/2018 78 War or Dates
-
Place of Death Hospital, Instituti of Lake Luzerne or_
1ason Dr.
City, Town or Village Street Address
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
® Circumstances Investigation
Medical Certifie Name Title
Inn l Ou aXeS I /A M n, N ci
Address
, ,.
Death Certificate Filed District Number Register Nu ber
City, Town or Village Lake Luzerne 5656 yL
❑Burial Dat Cemetery or Crematory
1 1 7, 1 Pine View Crematory
❑Entombment Add es 1
®Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
tag;
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St.,Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma a ains descr'bed ab s indicated.
Date Issued //,-,,,2_ Zj%,/Registrar of Vital Statisti
74 (signature)
District Number Place Town of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /I /s l I$ Place of Disposition �. (.-,
(ad ress)
• (section) (lot ff num (grave number)
Name of Sexton or Person in Charge of remises ("rt �,5,L"4)
(please print)
Signature4 Title Porn
(over)
DOH-1555 (02/2004)