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Mercant, Bruce I
SYs NEW YORK STATE DEPARTMENT OF HEALTH, Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Bruce I Merchant Male Date of Death Age If Veteran of U.S.Armed Forces, 10/06/2021 72 Years War or Dates 1970-1998 Place of Death Hospital,Institution or WCity,Town or Village Indian Lake Town Street Address 107 John Rust Road, Indian Lake Town, New York 12842 p Manner of Death ©Natural Cause ❑Accident ❑Homicide Suicide C 1 Undetermined Pending W U Circumstances Investigation W Medical Certifier Name Title 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 13 ❑Burial Date Cemetery,Crematory or Facility Name 10/07/2021 Pine View Crematory El Entombment Address iCremation Queensbury Town,New York Donation O ElRemoval Date Place Removed and/or and/or Held H Hold Address CO 0 a Date Point of U) ❑Transportation p 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 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/07/2021 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: W Date of Disposition /0$-Zpi/ Place of Disposition Prig,ri Q (Ai`t.t) L �` j (addre W N CC (section) 1 (lotnnumberII (grave number) O Name of Sexton or Person in Charge of Premises �f}�/�? 'S r F' (ilJ (please print) W Signature / ! �Title � T DOH-1555(o7/18)p 1 of 2 31 21 7) Public Health Law Sec. 4145(2b) Receipt 1 Human remains of /7 i-,!--74z:// delivered on ' , 20' Pine View Cemetery Representing the funeral home named on burial permit , Official Funeral Directors Reg.or License# /,‘