Stutz-Miller, Helga I ft, ~ li .3�NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle ' Last Sex
Helga Stutz-Miller Female
Date of Death If Veteran of U.S. Armed Forces,
10/17/2018 J Age 85 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Kattskill Bay Street Address 16 Mayflower Lane
W Manner of Death IX I Natural Cause n Accident Homicide Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Q Mason,MD
Address
100 Park Street,Glens Falls Cancer Center,Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5 6511 I y-1+
❑Burial Date Cemetery or Crematory
Entombment October 18,2018 Pine View Crematory
Address
ig].Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z II Removal and/or Held
and/or Address
H Hold
U)
O _ Date Point of
N Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Reinterment Date ! Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
Address
ILL''
W
a" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10-1 2 - a.0l8 Registrar of Vital Statistics --RAM- ,QQorL--
(signature)
District Number 5 k., 1 Place QU te-n S 6Ui
I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
IH
imDate of Disposition %o b1i to Place of Disposition 6,��.,,,� 4.
W (address)
CO
CC (section) (lot n be c (grave number)
0 Name of Sexton or Person in Charge of Premises ir,. JL%41
IZ / (please pn r t)
Signature 64 Title / i -
(over)
DOH-1555(02/2004)