Austin, Evelyn . • ft ,33
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iii7i: Name First Middle Last Sex Female
'<� Evelyn R Austin
r Date of Death = A e If Veteran of U.S. Armed Forces,
; 12/21/2011 g70 War or Dates No
''` Place of Death Hospital, Institution or
1 Town lAktil Long Lake Street Address 49 Clement Rd.
Manner of Death
'il Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Russell Rider MD
-: Address
El Long Lake,NY
:fix: Death Certificate Filed District Number I Register Number
-* On Town • 0' .0( Long Lake i'� 6F Date ; Cemetery of Crematory
is = ❑Burial 12/26/2011 i Pine View Crematory
Address
Li Cremation Queensbury,NY
} Date I Place Removed
...
❑Removal I and/or Held
and/or Address
Hold
Date I Point of
%El Transportation I Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
I
-- Reinterment Date ' Cemetery Address
Permit Issued to i Registration Number
"• Name of Funeral Home Miller Funeral Home 01199
Address
6357 State Rte. 30, Indian Lake,NY 12842
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
F Address
Permission is hereby granted to dispose of the human remains described above as indicated.
11
Fsi , Date Issued IL J2,111 egistr r of Vital Statistics
t_.,
*:. (signature)
.- !,,IDistrict Number Z.oS 6 _ Place V L0... Lp.u_
#`Y
I certify that the remains of the decedent identified above were disposed fin accordance with this permit on:
F
Zia Date of Disposition OM Zit Zc Place of Disposition Fnc�ieu CrrfteCtOf(uti.
(address)
(section) (lo number} (grave number)
° Name of Sexton or Pers in Charge Premises A., 5ta�g-
z (please print)
Signature Title CeeffinrTc(L
DOH-1555 (10/89) p. 1 of 2 VS-61