Miller, Robert NEW YORK STATE DEPARTMENT OF HEALTH F b
Vital Records Section -73
Burial - Transit Permit
.,a.
il Name First Middle Last Sex
Robert Walter Miller Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/10/2016 62 War or Dates
.. Place of Death Hospital, Institution or
City, Town or Village Brant Lake Street Address Deceased's Residence
Manner of Death X❑ Natural Cause 0 Accident El Homicide El Suicide EjUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
,l0 Address
kl"
'r- Death Certificate Filed District Number Register Number
`,,x City, j Town or Village , -i (..,_ 6p 524-- 0.
07,
0,'0O Burial Date Geuoete i or Cremato )
. ❑ 10/11/2016 f',q ' i iz Lf/ f ,- 'T r>f/,Y
gin Entombment Address ,t�} Z c�
®Cremation I; (j (la n-(4 Ul; r` t.� ,1'/rl7 . tf! j2--Pd r
Date Place Removed E
Removal and/or Held
and/or Address
Hold
' A Date Point of
Transportation Shipment
;' by Common Destination
Carrier
Disi -nterment Date Cemetery Address
Reinterment Date Cemetery Address
x Permit Issued to Registration Number
ti, Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
el Address
-44
PM 9 Pine St/P.O. Box 455 Chestertown NY 12817
gito Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w ' Permission is hereby granted to dispose of the human rem in escribed above as_indica d.
R.
1,45 Y Date Issued Registrar of Vital Statistics
P t (signature)
*s District Number 91- Place ,(`_` Gv \✓
i
loft
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition MMMit I it+ Place of Disposition - 0v".0, (c fin_„
`,
(address)
(section) (lot number) (grave number)
_. ��
Name of Sexton or Person in Charge of P emises � r,i � Se n,�b�
(ease print)
q
Signature 0 Title COCHat
(over)
DOH-1555(02/2004)