Miller, Shirley M 1
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley M.Miller Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/20/2021 90 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
1p Manner of Death Natural Cause El Accident ❑Homicide Suicide El Undetermined El Pending
VCircumstances Investigation
W Medical Certifier Name Title
Heather Madigan DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 679
ElBurial Date Cemetery,Crematory or Facility Name
11/23/2021 Pineview Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
F—N Hold Address
0
f2 Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
g Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/23/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, 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 il 124 Place of Disposition I �
W (address)
W
NCC (section) Ai (lot number) (grave number)
Name of Sexton or Person in Charge Premises 1(s(plea
e print)
W Signature Title `i44 �
DOH-1555 l07/18)p 1 of 2
015402
Public Health Law Sec. 4145(2b)
Receipt
Human remains of _ delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#