Powers, Richard J. Jr. .,..0,.._____r..,,,.)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard J Powers Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/03/2022 88 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Elizabethtown Town Street Address Elizabethtown Community Hospital
W
p Manner of Death 0 Natural Cause Accident nHomicide Suicide ❑Undetermined ElPending
tL Circumstances Investigation
WMedical Certifier Name Title
CI II Chon MD
Address
75 Park Street PO Box 277, Elizabethtown Town,New York 12932
Death Certificate Filed Town Of Elizabethtown District Number Register Number
City,Town or Village 1552 98
Burial Date Cemetery,Crematory or Facility Name
® 12/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
EL Date Point of
Cl) Transportation
Q by Common Shipment
Carrier Destination
El
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
2 Address
Q
W
fl" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/07/2022 Registrar of Vital Statistics Janet E Cross(Electronically Signed)
(signature)
District Number 1552 Place Town Of Elizabethtown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: (4.
1- -WDate of Disposition 2 31ZZ Place of Disposition Iti --�
2 (address)
W
NCC (section) 4(lot,number) ,� (grave number)
a Name of Sexton or Person in Char Premises ��"'"�'
(plea print) ��
g
lL (17"Signature Title "(
DOH-1555(o7/18)p 1 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 Funer 'rectors Reg.or License#