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Matthews Jr. Hugh F ttiioo NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Hugh F.Matthews Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/06/2020 69 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Indian Lake Town Street Address 267 Chamberlain Road, Indian Lake Town,New York 12842 • Manner of Death Ej Natural Cause ❑Accident ❑Homicide Suicide ©Undetermined ❑Pending W C.) Circumstances Investigation W Medical Certifier Name Title CI Matthew Miller Coroner Address "P.O.Box 250, Indian Lake,New York 12842 Death Certificate Filed District Number Register Number City,Town or Village Indian Lake 2053 13 Burial Date Cemetery,Crematory or Facility Name 11/12/2020 Pine View Crematory ElEntombment Address 0 Cremation Queensbury Town, New York ElDonation ZO Removal Date Place Removed and/or and/or Held Hold Address N 0 0. Date Point of t/) 1-1 Transportation Shipment by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above g Address Q W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2020 Registrar of Vital Statistics Julie A Clawson(Electronically Signed) (signature) District Number 2053 Place Indian Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 11-0Z Date of Disposition II I 131 ZO Place of Disposition � � �*�— W (address) W CC CC (section/ (lot number) (grave number) o rii L qc{It O Name of Sexton or Person in Charge of Premises (p ase print) W Signature Title 61� DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) _ - .41 Receipt Human remains of delivered on,'4' '' , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#