Johnson, Marjorie June 1 LF) 1)3
NEW YORK STATE DEPARTMENT OF HEALTH ` Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marjorie June Johnson Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/08/2022 89 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 385 Ridge Road,Queensbury Town,New York 12804
p Manner of Death ❑X Natural Cause nAccident ❑Homicide Duicide FlUndetermined FiPending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 Robert Reeves MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 96
Burial Date Cemetery,Crematory or Facility Name
06/09/2022 Pine View Crematory
Entombment Address -h.
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
F.,
N Hold Address
0
O. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/09/2022 Registrar of Vital Statistics Caroline xldegarde Barber(ECectronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ii lioi 72 Place of Disposition -17Il —
UJ (address)
W
Cl)CC (section) lot number) Shy grave number)
0 �
Name of Sexton or Person in Charge of Premises It
�
Z L (Please+Printl
1!J ` ��
Signature //�J,r� f� Title
DOH-1555(07/18)p 1 of 2
.
0 ,. 578
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#