Millis, Gary Charles NEW YORKSTATE DEPARTMENT OF HEALTH Burial -Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary Charles Millis Male
Date of Death Age If Veteran of US.Armed Forces,
01/27/2023 69 Years War or Dates
F,. Place of Death Hospital,Institution or
W City,Town or Village Corinth Town Street Address 466 Angel Road,Corinth Town,New York 12822
p Manner of Death ❑X Natural Cause Accident Homicide uSuicide nUndetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 George Siniapkin MD
Address
604 Palmer Avenue,Corinth Town,New York 12822
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 1
Burial Date Cemetery,Crematory or Facility Name
Entombment Address
['Cremation
Donation
Removal Date Place Removed
Q 01/28/2023 and/or Held Corinth Rural Cemetery
H and/or
Hold Address
0 Corinth Village, New York
D. Date Point of
(I)❑Transportation Shipment
p by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
a Address
CC
W
Q.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2023 Registrar of Vital Statistics Brenda L Penis(Electronically Signed)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition 2 1 1 Z3 Place of Disposition
2 (address)
W
CC N /sectaon/ // (lot number) (grave number)
g Name of Sexton or Person in Charge Premises Y
lease print)
W
Title (PA at
r��Signature
DOH-1555(o7/18)p i of 2
6 ! *;
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#