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Johnson, Robert F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert F.Johnson Male Date of Death Age If Veteran of U.S.Armed Forces, 01/20/2022 95 Years War or Dates WWII/Korean Place of Death Hospital,Institution or Z City,Town or Village Stony Creek Town Street Address 114 Fodder Rd,Stony Creek Town, New York 12878 Manner of Death Pending 0 ©Natural Cause �Accident �Homicide �Suicide �Undetermined � W Circumstances Investigation W Medical Certifier Name Title O Paul Bachman MD Address 9 Carey Rd,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Stony Creek 5658 1 ElBurial Date Cemetery,Crematory or Facility Name 01/21/2022 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York ElDonation ZO ❑Removal Date Place Removed and/or and/or Held Hold Address 0 G. Date Point of f/) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/21/2022 Registrar of Vital Statistics Susan I Harrington(Electronically Signed) (signature) District Number 5658 Place Stony Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: - WDate of Disposition h z Z-ZOZZ Place of Disposition �° A V„e,,,L,> C ri41 f ft 2 (address) W CC CC (section) (lot num r) (grave number) O ©G) ea Name of Sexton or Person in Charge of Premi s Z > Tease print) W Signature / Title ae c DOH-1555(07/18)p t 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#