Loading...
Shortt, James T #L3Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James T.Short Male Date of Death Age If Veteran of U.S.Armed Forces, 07/31/2021 78 Years War or Dates 1959-1963 Place of Death Hospital,Institution or Z City,Town or Village Indian Lake Town Street Address 123 Starbuck Road, Indian Lake Town, New York 12842 lit p Manner of Death © Natural Cause El Accident El Homicide ❑Suicide ❑ Undetermined ❑Pending VCircumstances Investigation CI Matthew Certifier Name Title 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 7 ❑Burial Date Cemetery,Crematory or Facility Name 08/03/2021 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ▪Donation 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 a. Date Point of N ❑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 Remains are Shipped,If Other than Above 5 Address C W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/03/2021 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 gill Ill Place of Disposition �Y� li.r or��. W 2 (address) W N (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of P emises (pie 6)tL '�' Z a print) /� W Signature Il + Title 4r`'���re DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 1- Receipt Human remains of , delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#