Millis, Margaret NEW YORK STATE DEPARTMENT OF HEALTH w - L S 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Margaret E. Millis Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/10/2012 78 years War or Dates
f. Place of Death Hospital, Institution or
iTi City, T4 t Rr)(7N C Saratoga S rings Street Address Saratnga Hnspital
0 Manner of Death w Natural Cause Accident ❑Homicide ❑Suicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
Q Richard Kim M D
Address '
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, Tg Rr X,M Saratoga Springs 4501 533
❑Burial Date Cemetery or Crematory
['Entombment Pineview Crematorium
Address
LCremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
0 and/or
Address
N
Hold
0 Date Point of
ti ❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
ei Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
X.
ill
P:` Permission is hereby granted to dispose of the human remain "be,�aboy�,as i dicated.
il Date Issued 12/11/2012 Registrar of Vital Statistics U�'(Jw�� r'
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition f 7, 13`tt Place of Disposition Pau,) /4,,, C.14,11.4 id t,J,r•.
2 (address)
ILI
WI
CC (section) 4 number) (grave number)
Name of Sexton or Person in Charge Premises 6i sti- l it44111-
z. (please pirint)
Signature £4 Title C A- it-
(over)
DOH-1555 (02/2004)