Miller. Mollie Jane itlot1
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mollie Jane Miller Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/25/2020 73 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 12 5th Street,Glens Falls,New York 12801
ILI
Manner of Death El NaturalCause ❑Accident Homicide ❑Suicide ❑Undetermined El Pending
V Circumstances Investigation
G Medical Certifier Name Title
Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 437
❑Burial Date Cemetery,Crematory or Facility Name
09/29/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury,New York
❑Donation
g ❑Removal Date Place Removed
and/or and/or Held
— Hold Address
U) ❑Transportation Date Point of
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
EjReinterment 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
E.. Remains are Shipped,If Other than Above
Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/28/2020 Registrar of Vital Statistics RP6ert Andrew Curtis(Ekaronicaf Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition tot Zjp Place of Disposition Zi....1/1...
4-0,N.,...-
tu (address)
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N CC (section) hot number/ (grave number)
O Name of Sexton or Person in Charge of Premise 1 --��,,,�.1�}
Z (pleasgprint)
W Si nature C.✓' X.,—, � Title " ' ""
g
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 01 4"0 5
Receipt
Human remains of delivered on , 20�.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#