Millis, Robert J. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert J Millis Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/10/2019 68 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide g
Circumstances Investigation
W Medical Certifier Name Title
Anthony Pemiciaro Coroner
Address
45 NATIVE DANCER LN,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 599
Burial Date Cemetery,Crematory or Facility Name
11/15/2019 Pineview Crematory
Entombment Address
nCremation Queensbury Town,New York
❑Donation
Q Removal Date Place Removed
and/or and/or Held
i- Hold Address
U)
O
a Date Point of
fA ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Q
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/13/2019 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition iif is��� Place of Disposition r�
LU (address)
W
N (section) 110t number/ (grave number)
Ix
0 Name of Sexton or Person in Charge of Premises
/p!ase print)Z
W Signature (,� �� Title 't
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01 13 8
Receipt
Human remains of �ti, '' delivered on , 20y
Pine View Cemetery kep enting the funeral home named on burial permit
Official Funeral Directors Reg.or License#