Brock, Cheryl A 767
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cheryl A.Brock Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/01/2021 75 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Long Lake Town Street Address 88 Whispering Woods Way,Long Lake Town,New York 12847
Manner of Death Undetermined 1=1Pending
W ❑Natural Cause Accident ❑Homicide Suicide ❑
C) Circumstances Investigation
W Medical 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 Long Lake 2056 6
❑Burial Date Cemetery,Crematory or Facility Name
09/10/2021 Pine View Crematory
ElEntombment Address
ElCremation Queensbury Town,New York
ElDonation
❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
Q. 1-1 Date Point of
U) ❑Transportation
p by Common Shipment
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
Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/10/2021 Registrar of Vital Statistics Dixie Lee Leblanc(Electronically Signed)
(signature)
District Number 2056 Place Long 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 9//.oZi Place of Disposition ? ,,.e (,,:.e.,J C n
/`Lima
2 (addressJJ
W
CC (section) � �/ (lot number) (grave number)
Name of Sexton or Person in Char of Premise /Gti/ ji n' �d
Z please print)
Signature Title Q
DOH-1555(07/18)p t of 2
I i ,
Public Health Law Sec. 4145(2b) "" x`
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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