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Johansen, Thomas S
k. n-F tt -7 a_ N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas S.Johansen Male Date of Death Age If Veteran of U.S.Armed Forces, 01/18/2024 83 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing W Manner of Death Undetermined Pending W I—INatural Cause Accident Homicid Suicide g Circumstances Investigation W Medical Certifier Name Title 0 Mikram Jafri MD Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 13 Burial Date Cemetery,Crematory or Facility Name MIME 01/19/2024 Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of N Transportation p by Common Shipment Carrier Destination Date Cemetery Address nDisinterment n Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom 1— 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 01/19/2024 Registrar of Vital Statistics Caroline fiegarde Barber(ECectronicafySigned) (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: I— Z Date of Disposition I I ZZ 12Lj Place of Disposition ,rip/cV✓t=.J (I m} U" 2 (address) W � (section) (lqt�tuber) �� (grave number) 0 Name of Sexton or Person in Charge of Premises �'� Z Ze (/lease print) �" pWSignature Title ` Pi 9t� DOH-1555(07/18)p 1 of 2 .y ,.n .E t 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#