Miller, Stanley NEW Yc RK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
{2,
;f Name First Middle Last Sex
Stanley James Miller Male
Date of Death Age If Veteran of U.S. Armed Forces,
. June 4,2014 92 War or Dates
,''' Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 1903 Ridge Road
Manner of Death I X1 Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Andrew Garner,MD
0Address
f Harrison Ave,Glens Falls,NY
,. Death Certificate Filed District Number Reqister Number
fj City, Town or Village Queensbury,NY 5657 (
❑X Burial Date Cemetery or Crematory
June 6, 2014 Seelye Cemetery_
❑Entombment Address
❑Cremation Ridge Road, Queensbury, NY 12804
Date Place Removed
Z
U Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
5,t
Permit Issued to Registration Number
'% Name of Funeral Home Regan Denny Stafford Funeral Home 01443
I Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1Remains are Shipped, If Other than Above
Address
f Permission is hereb granted to dispose of the human e ins described above as indicated.
Date Issued Registrar of Vital Statistics C� Q .
signature v)
District Number 5657 Place Queensbury,NY
',r.,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 6/6/2 01 4 Place of Disposition Seelye Cemetery
W (address)
() Family Plot
(section) (lot number) (grave number)
Q Name of Sex n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signature ALL& - 'Q vv' Title Superintendent
C (over)
DOH-1555(02/2004)