Tomlin, Elizabeth G. NEW YORK STATE DEPARTMENT OF HEALTH 13 I
Burial - Transit Permit
Bureau of Vital Records
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Name First Middle Last Sex
Elizabeth G.Tomlin Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/03/2021 84 Years War or Dates
F-. Place of Death Hospital,Institution or
Z City,Town or Village Indian Lake Town Street Address 133 Mountain Top Drive, Indian Lake Town,New York 12842
p Manner of Death Natural Cause ❑Accident Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed District Number Register Number
City,Town or Village Indian Lake 2053 2
❑Burial Date Cemetery,Crematory or Facility Name
02/04/2021 Pine View Crematory
EjEntombment Address
X❑Cremation Queensbury Town,New York
❑Donation
ZZ Removal Date Place Removed
and/or and/or Held
H Hold Address
0
a Date Point of
U) ❑Transportation
by Common Shipment
Carrier Destination
❑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
1— Remains are Shipped,If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/04/2021 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:
Z Date of Disposition 219 111 Place of Disposition
L Gam_
lU ddress)
W
CC (section) /pit number/ (grave number)
Name of Sexton or Person in Charge of Pre ises
Z (please#int
LU Signature Title (WrA61409if
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 1'1 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#