Millis Sr., Thomas NEW YORK STATE DEPARTMENT OF HEALT4 a ,L #' l117
i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas E. Millis Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/18/2018 74 years War or Dates
Place of Death Hospital, Institution or
Town okydblieGreenfield Street Address 187 North Greenfield Rd. Porter Corners, New_
anner of Death Ldj Natural Cause O Accident O Homicide 0 Suicide Undetermined Pending
tV Circumstances Investigation
tu Medical Certifier Name Title
Roland Phillips Md
Address
6 Care Lane, Saratoga Springs, N Y 12866 •
Death Certificate Filed . District Number Register Number
Town o. Greenfield 4557 12
OBurial Date Cemetery or Crematory
❑Entombment 06/19/2018 Pineview Crematorium
Address
(Cremation Queensbury, N Y
Date Place Removed
O Removal and/or Held
and/or Address
i= Hold
in
O Date Point of
d' 0 Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Avenue, Corinth, New York 12822
Ai Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X Address
tr
tU
""` Permission is hereby granted to dispose of the human r mains described above a indicated.
Date Issued 06/19/2018 Registrar of Vital Statistics S - 11 p
(signature)
<i District Number 4557 Place Greenfield
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 4'/t2 li g Place of Disposition U.../ t'Lto.-•'
2 (address)
LU
t
(section) /il (lot number) (grave number)
1.4
ci Name of Sexton or Person in Charge of Premises G^'v S�^^'
(pl ase print)
14 Signature !s( Title
(over)
DOH-1555 (02/2004)