Johnsen, Peggy Sue Pi S i Z
NEW YORK STATE DEPARTMENT OF HEALTH >„,,;, ;; .. ,
Burial - Transit Permit
Bureau of Vital Records
Last Sex
Name v First Middle Female
Peg y Sue Johnsen
Date of Death Age If Veteran of U.S.Armed Forces,
06/27/2022 53 Years War or Dates
F Place of Death Street Address
Institution or
ddress 112 Oak Street Apt. B,Corinth Town, New York 12822
Z City,Town or Village Corinth TownUndetermined ElPending
0 Manner of Death 0 Natural Cause Accident Homicide Suicide
W Circumstances g Investigation
V Name Title
W Medical Certifier DO
0 John Pezzulo
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Corinth District Number Register Number
4553 12
City,Town or Village
Date Cemetery,Crematory or Facility Name
Burial
® 06/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
❑Removal and/or Held
H and/or Hold Address
N
0
CL I Point of
CO❑Transportation Date Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
g Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/27/2022 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
(signature/
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition `I*n Place of DispositionILI
�n1 16,. yt""ma.
W Wohtel
us
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o
lse�iao/ / �
Name of Sexton or Person in Charge of Premises
Z
W
Signature tll
d'DOH-lsSS/o7/18J rrtie /pip
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name s First Middle Last Sex
Peggy Sue Johnsen Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/27/2022 53 Years War or Dates
Place of Death FTospital,Institution or
Z City,Town or Village Corinth Town Street Address 112 Oak Street Apt. B,Corinth Town, New York 12822
LLI
p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
C.) Medical Certifier Name Title
CI John Pezzulo DO
Address
211 Church St,Saratoga Springs, New York 12866
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 12
Burial Date Cemetery,Crematory or Facility Name
06/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
- Hold Address
N
O
o. Date Point of
(/) 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
— Remains are Shipped,If Other than Above
g Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/27/2022 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition i,11gj 7L471 Place of DispositionV�--- Z --"":
tL (address)
W
N (section) AL,
/ot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
(pitase print)
W fi Signature ) Title �
DOH-1555(07/18)p t of 2
j 'I ".6 01
Public Health Law Sec. 4145(2b)
1 Receipt
Human remains of delivered on , 24`
1
Pine View Cemetery Representing the funeral home named on burial permit
' cial Funeral Directors Reg.or License#