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Johnson, Edith NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Edith E.Johnson Female 1 Date of Death Age If Veteran of U.S. Armed Forces, 05/09/2018 89 Years War or Dates ..7 Place of Death Hospital, Institution or City, Town or Village Johnsburg Town Street Address Adirondack Tri-County Nursing And Rehabilitation Center,Inc. Manner of Death© Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending Circumstances Investigation 1-. Medical Certifier Name Title James Hindson MD Address L 112 Ski Bowl Rd,Johnsburg Town, New York 12853 • Death Certificate Filed District Number Register Number City, Town or Village North Creek 5655 14 ❑Burial Date Cemetery or Crematory 05/10/2018 Pine View Crematory El Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held LI and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address -- tt Reinterment Date Cemetery Address _ Permit Issued to Registration Number ``- Name of Funeral Home Brewer Funeral Home Inc 00211 Address S' 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address tg Permission is hereby granted to dispose of the human remains described above as indicated. ', Date Issued 05/10/2018 Registrar of Vital Statistics ?cjitkleen C.torah(E(ectronicallySigned) 1 (signature) District Number 5655 Place North Creek, New York certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition S/ii /tf Place of Disposition atV.,. X-e1on--- ', (address) (section) Ai (lot numbs ) (grave number) Name of Sexton or Person in Charge of Premises 1 please print) Tr • 4• ' Signature 0Title /R isi.. , (over) DOH-1555 (02/2004)