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Miller, Irene NEW YORK STATE DEPARTMENT OF HEALTH # "' 3-) Vital Records Section Burial - Transit Permit Name First Middle Last Sex Irene J. Miller Female Date of Death Age If Veteran of U.S. Armed Forces, June 13,2014 92 War or Dates i.,. Place of Death Hospital, Institution or •Z City, Town or Village Lake Pleasant Street Address 115 Old Indian Lake Rd. ILI Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation V. uf Medical Certifier Name Title ©° Paul R.Perreault Dr. Address ,Mayfield,NY 12117 Death Certificate Filed District Number Register Number City, Town or Village Lake Pleasant 2.6 S ❑Burial Date Cemetery or Crematory Entombment June 17,2014 Pine View Crematory Address ❑x Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold 0 0 Date Point of 1 1 Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date • Cemetery Address 1 Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street, Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above j Address itz= Permission is hereby granted to dispose of the huma remains described a e as indicated. Date Issued 6/j b l i(-I Registrar of Vital Statistics i Ji..,,g ,zy ....e___ signature) District Number ao6- < Place Lake Pleasant I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ii� ui Date of Disposition (Q AI pi Place of Disposition ?'r,.s(kJ 6 pvtor�w-- E (address) W co pcc (section) £(lot number) � (grave number) Name of Sexton or Person in Charge of Premises er,i{ 1.c.. Je Wit Z (Tease print) w Signature 41— Title C12A l (over) DOH-1555 (02/2004)