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Johnson, Judiith Ann
0 tt NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Judith Ann Johnson Female Date of Death Age If Veteran of U.S.Armed Forces, 03/05/2023 81 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Fort Edward Town Street Address 325 Broadway Apt.54,Fort Edward Town,New York 12828 p• Manner of Death Natural Cause Accident ❑Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Lisa Armao NP Address 319 South Manning Boulevard 301,Albany,New York 12208 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 28 Burial Date Cemetery,Crematory or Facility Name 03/07/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation o Removal Date Place Removed and/or and/or Held F- Hold Address 0 O. Date Point of Cl) Transportation p by Common Shipment Carrier Destination ODisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address B1 O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/07/2023 Registrar of Vital Statistics Aimee L Makoney(E(ectronicalty Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 319 (13 Place of Disposition 2 (address) W CC N (section) (lot number) (grave number) S �i ..r It( Name of Sexton or Person in Charge of Pre es ;lease print) W Signature Title (PonfrP2 DOH-1555(07/18)p 1 of 2 ,0") . -7 >� 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#