Holmes, Paul A , i ,-): ,,,, _,
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Paul A. Holmes Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/24/2022 72 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Indian Lake Town Street Address 186 We-Yo Trail, Indian Lake Town, New York 12842
W
p• Manner of Death ❑x Natural Cause IllAccident 0Homicide n n
Suicide Undetermined ❑Pending
fI 'Circumstances Investigation
W• Medical Certifier Name Title
CI Ryan Donnelly DO
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Indian Lake District Number Register Number
City,Town or Village 2053 10
RBurial Date Cemetery,Crematory or Facility Name
12/27/2022 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town, New York
▪Donation •
0 L._I val Date Place Removed
and/or and/or Held
H Hold Address
N
0
EL Date Point of
Cl)ETransportation
Q by 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
F Remains are Shipped,If Other than Above
2 Address
IE
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
g Date Issued
12/27/2022 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:
I— � /
Z Date of Disposition /Z-Z 2v7Z Place of Disposition Y' „f e (J,. J Crvmw. "�
UJ (address)
W
NCC (section) /lot mberl (grave number)
0 Name of Sexton or Person in Charge o PreJ
AS���� UGC"
(please print)
Z
W Signature `� b Title Gr+erw-4
DOH-1555(07/18)p 1 of 2
G
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#