Powers, Lorraine C # Z 51,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lorraine C.Powers Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/16/2022 82 Years War or Dates
F. Place of Death Hospital,Institution or
WCity,Town or Village Indian Lake Town Street Address 241 Adirondack Road, Indian Lake Town, New York 12842
C3 Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined El Pending
ILI
V Circumstances Investigation
Q Medical Certifier Name Title
Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Indian Lake District Number Register Number
City,Town or Village 2053 2
Burial Date Cemetery,Crematory or Facility Name
03/21/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
ZZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d. Date Point of
(f) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
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
1— Remains are Shipped,If Other than Above
2 Address
Cr
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/17/2022 Registrar of Vital Statistics Julie A Clawson(Electronically Signed)
(signature)
District Number 2053 Place Town Of Indian Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 31 1Z Z2 Place of Disposition to
2 (address)
W
N
CC (section) ,f (lot number) (grave number)
GName of Sexton or Person in Charge of Premises `/►(� � '"��
Z please print)6..27
W Signature 7/1Title
DOH-1555(07/18)pi of 2
Q"i r f,j &";
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#