Bird, James C (L.r7:\
tfid
NEW YORKSTATE DEPARTMENT OF HEALTH � Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James C.Bird Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/03/2022 70 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Indian Lake Town Street Address 155 Chamberlain Road, Indian Lake Town, New York 12842
p Manner of Death ❑X Natural Cause Accident Homicide OSuicide Undetermined ri Pending
W Circumstances Investigation
U
W 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 6
Burial Date Cemetery,Crematory or Facility Name
1 06/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,Warren, New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a. Date Point of
N Transportation
by Common Shipment
Carrier Destination
O
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
H Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2022 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:
W Date of Disposition I,(1 I ZZ Place of Disposition f J,._ ., p!1-_—._'
2 (address)
W
N CC (section) (lot number) (grave number)
_
gName of Sexton or Person in Charge of Premises t'� �iv1hAt
Z ease print) /�.,�
IL Signature <�" � Title ' rw''' �
DOH-1555(07/18)p 1 of 2
s w,
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#