Doherty, Sheila J . , LF)NEW YORKSTATE DEPARTMENTOF HEALTH \ r Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sheila J.Doherty Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/11/2022 62 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village Harrietstown Town Street Address Adirondack Medical Center-Saranac Lake Site
p Manner of Death II Natural Cause Accident 0 Homicide Suicide ❑Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
O Jessica Shumway PA
Address
2233 State Rte 86 PO Box 471,Harrietstown Town,New York 12983
Death Certificate Filed Town Of Harrietstown District Number Register Number
City,Town or Village 1663 89
Burial Date Cemetery,Crematory or Facility Name
10/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
0. Date Point of
Cl) Transportation
0 by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
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
2 Address
CC
tU
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2022 Registrar of Vital Statistics Donna Kay Sayles(Electronically Signed)
(signature)
District Number 1663 Place Town Of Harrietstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W~ L
Date of Disposition jp Icy I7L Place of Disposition ,,,_l
2 (address)
LU
CO
IX (section) (lot number) (grave number)
O Name of Sexton or Person in Charge Premises ��v "VI
/ ease print)
Z
W Signature i Title (211/Ynti
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Fi. .IA1'
Receipt
Human remains of delivered on , 20
Rine View Cemetery Representing the funeral home named on burial permit
%Official Funeral Directors Reg.or License#