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Miller, Pauline M
Zoe$ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Pauline M Miller Female Date of Death Age If Veteran of U.S.Armed Forces, 02/21/2021 93 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek p Manner of Death © Natural Cause 0 Accident Homicide 0 Suicide El Undetermined n Pending W C.) Circumstances I 'Investigation W Medical Certifier Name Title Madison Zuis NP Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 6 0 Burial Date Cemetery,Crematory or Facility Name 02/23/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation ZZ ❑Removal Date Place Removed and/or and/or Held Hold Address N 0 CL Date Point of U) ❑Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Edward L Kelly Funeral Home 00519 Address PO Box 548,Schroon Lake,New York 12870 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above M Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/23/2021 Registrar of Vital Statistics Katk(een C.Lorak(E(ectronica((y Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 2," 2t9-Zo4 c/Place of Disposition f h� �r� � L-r Liv n.- / (address) W CC N (section) (lot number) (grave number) 0 Name of Sexton or Per n in C rge 1mise5 !.. r14.✓i. 64 Y! Z (please print) W Signature Title C'rGs.+ T '1 U er: DOH-1555(07/18)p f 2 IN, Public Health Law Sec. 4145(2b) j 14 5 7 5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#