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Walden, Donna M. NEW YORKSTATE DEPARTMENT OF HEALTH r Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donna M.Walden Female Date of Death Age If Veteran of U.S.Armed Forces, 04/12/2020 82 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined El Pending W Circumstances Investigation U W Medical Certifier Name Title Michael Miles MD Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 12 ❑Burial Date Cemetery,Crematory or Facility Name 04/13/2020 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation zRemoval Date Place Removed and/or and/or Held _ F- N Hold Address O d Date Point of to ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment I Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/13/2020 Registrar of Vital Statistics Kathleen C. Lorah(Electronically Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition L/l/yJ la Place of Disposition L &0 W 2 (address) W N (section) (lot number) (grave number) III 0 Name of Sexton or Person in Charge of Premises A. f lease print) Z / W Signature Title DO H-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) �_ S Receipt Human remains of delivered on , 20 -1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#