Pierson, Nancy L NEW YORKSTATE DEPARTMENT OF HEALTH \ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nancy L. Pierson Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/24/2022 83 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Indian Lake Town , Street Address 7990 State Route 30, Indian Lake Town, New York 12812
1p Manner of Death Natural Cause Accident 7Homicide ESuicide Undetermined ❑Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI 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 9
Burial Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
EIDonation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
U? Transportation
El Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
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
5 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 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 11 ( Lg j 14_ Place of Disposition
2 (address)
W
(section) number) /�/grave number/
0 Name of Sexton or Person in Char a of Premises /7,,,,t ( `
Z (pleafe print) /
W Signature Title ` ,,,pc
DOH-1555(07/18)p t of 2
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#