Miller, Florence NEW YORK STATE DEPARTMENT OF HEALTH w • • ►Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Florence W. Miller Female
= Date of Death Age If Veteran of U.S. Armed Forces,
April 23, 2012 89 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Westmount Health Facility
pManner of Death I X]Natural Cause Accident I I Homicide Suicide 1 I Undetermined Pending
U.I. Circumstances Investigation
W Medical Certifier Name Title
. Roslyn Scolof MD
Address
42 Gurney Lane,Queensbury,NY 12804
Death Certificate Filed ilaiktrict Number Re ister Number
City, Town or Village Queensbury t_9 J 9
❑Burial Date Cemetery or Crematory
April 24, 2012 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
2 and/or Address
H Hold
O Date Point of
yI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ( Registration Number
Name of Funeral Home �'q c,,� \ .) -��� ,Y;r� Z� � 01443
Address k--,. _
53 Quaker Road, Queensbury, NY 12804
3 Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2 Address
W
a
Permission is hereby granted to dispose of the human remains described abp e as indicated.
Date IssuedL{ �S-{ oaQ) tegistrar of Vital Statistics C_ --,,
(signature)
District Number c --) Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z n /�
W Date of Disposition tI 1jli Place of Disposition 42tu, ,t.) C re4ifot,,,,,
2 (address)
W
U)
rl
0 (section) (lot number) (grave number)
pp Name of Sexton or Pers n in Charge f Premises tAt,�} ., S,{tf
Z I (please print)
Witfk._
Signature Title C wvq.,Foi-
(over)
DOH-1555(02/2004)