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Miller Jr. , Cassius J. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cassius J.Miller Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 03/03/2020 100 Years War or Dates 42-45 Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing p Manner of Death Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending Circumstances Investigation V Medicat Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 ---] Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 37 ©Burial Date Cemetery,Crematory or Facility Name 03/09/2020 Pine View Cemetery Entombment Address Cremation Queensbury,New York Donation ZO Removal Date Place Removed ~ and/or and/or Held N Hold Address O 0• Date Point of to ❑Transportation a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address Ix a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/05/2020 Registrar of Vital Statistics Caroline x(degarde Ear6er(E(ectronicallySigned) /signature/ District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3/9/2020 Place of Disposition 21 Quarker Rd. Queensbur IVY 12804 Uj Uj (address) W M (section) (/otnumber) (grave number) 8 Name of Sexto r Person in Chi a Premises ConnieAGoedert lease print)Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010373 Receipt Human remains of delivered on , 20— Pine View CeT! Representing the funeral home named on burial permit Official ` Funeral Directors Reg.or License# — Miller Jr. NAME Cassius J. Miller Age: 100 Lot Owner: Cassius J. Miller Lot# Mohawk Grave#1 Case: Concrete Died: 3/3/2 0 2 0 Interred: 3/9/2 0 2 0 Funeral Home:Regan Denny Stafford Cemetery: pine View