Mills, Richard g'z c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
l
Name First Middle Last Sex
Richard . P. Mills Male
Date of Death Age If Veteran of U.S. Armed Forces,
an November 1,2017 72 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address Old Farm Road
W Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
O William Orluk
Address
Chester Health Center,Chestertown,NY 12817
Death Certificate Filed I District Number Register Number
City, Town or Village Johnsburg 5655 1��
❑Burial Date Cemetery or Crematory
November 3,2017 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
ai I 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I_- Remains are Shipped, If Other than Above
Address
CC
tit/
O. Permission is hereby granted to dispose of the hums ema I s des bove a ' icated.
Date Issued 11-a- 1-'7 Registrar of Vital Statisti ID
(signatu e)
District Number aci Place ,(\` "f(
I certify that the remains of the decedent identified above were ir.ilosed of in accordance with this permit on:
Z p
Ill Date of Disposition /41,I(� Place of Disposition fi.+t),,,,/ avi.r/la...�
W (address)
Cl)
W (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premisesjc,il�. S 1,.. '
'Z (pi ase print)
Signature v'( -4 Title C464$
(over)
DOH-1555 (02/2004)