VanBumble, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH 3- . a 4 "1.
Vital Records Section Burial - Transit Permit
Name First Doroth Middle Last Sex Female
y L. VanBumble
Date of Death Age 1 If Veteran of U.S. Armed Forces,
2/8/2012 85 I War or Dates no
Place of Death j Hospital. Institution or
Town%SR Indian Lake Street Address 113 John Rust Rd.
Manner of Death fjj Natural Cause Accident �Homicide Suicide PP . ri Undetermined Pending
Circumstances Investigation
• Medical Certifier I,Name Title
Address
Indian Lake,NY
Death Certificate Filed I Districc,,Number Register Number
¢C TownXMONX Indian Lake O 5 tI
Date ' Cemetery or Crematory
0 Burial E 2/9/2012 Pine View Crematory
Address
Cremation Queensbury,NY
• Date Place Removed
Z❑Removal and/or Held
and/or
Address
Hold
Date ' Point of
e,Q Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 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
t`"" Remains are Shipped. If Other than Above
Address
,1 Permission is hereby granted to dispose of the human em ins descri d ove as indicated.
3 Date Issued I cf i.�. Registrar of Vital Statistics j c., 4, IQ ,
"' ) ( gnature)
District Numbers (j Place IC'/4>; bi, b)61.(i.,i'
1`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I. Ir
Date of Disposition iz� iy t tO+Z Place of Disposition ..L L � f«
2 (address)
tlt
CA
CC (section) // (lot number) r (grave number)
GName of Sexton or Peron in Charg of Premises h�.,A 3i
Z (please print)
W Signature Title c cn Rim..
DOH-1555 (10/89) p. 1 of 2 VS-61