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Johnpeer, Jessie R. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jessie R Johnpeer Female Date of Death Age If Veteran of U.S.Armed Forces, 01/26/2021 84 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Milton Town Street Address 804 Middleline Rd,Milton Town,New York 12020 p Manner of Death ©Natural Cause El Accident I=1 Homicide Suicide 0 Undetermined El Pending W 0 Circumstances Investigation Wp Medical Certifier Name Title Patricia Ford MD Address 445 New Kamer Road,Colonie Town,New York 12205 Death Certificate Filed District Number Register Number City,Town or Village Ballston Spa 4561 008 ❑Burial Date Cemetery,Crematory or Facility Name 01/28/2021 Pineview Crematory El Entombment Address 0 Cremation Queensbury Town,New York ElDonation 0 Removal Date Place Removed and/or and/or Held • Hold Address 0 NLi Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above M Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/27/2021 Registrar of Vital Statistics Brenda Howe(Electronically Signed) (signature) District Number 4561 Place Ballston Spa, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH WDate of Disposition �5 '71 Place of Disposition IL. 2 (address) W N (section) (1 umber) (grave number) O Name of Sexton or Person in Charge of Premises /1r, �jpLw�Jh 7 (Please pfint) �� lL Signature Cr Title (infv/ii 1"1'L DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#