Haynes, Letty E It ( 73
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Letty E. Haynes Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/04/2023 96 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Utica Street Address St Elizabeth Medical Center
LU
p Manner of Death �Natural Cause Accident Homicide []Suicide Undetermined []Pending
VCircumstances I /Investigation
W Medical Certifier Name Title
O Rashid Girshab MD
Address
2209 Genesee Street, Utica, New York 13501
Death Certificate Filed City Of Utica District Number Register Number
City,Town or Village 3202 105
Burial Date Cemetery,Crematory or Facility Name
02/06/2023 Pine View Crematory
Entombment Address
IIICremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
d Date Point of
Cl) Transportation
p 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
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2023 Registrar of Vital Statistics Tatiyana Brooks(Electronically Signed)
(signature)
District Number 3202 Place City Of Utica
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ � C
Z Date of Disposition 2 (p I 73 Place of Disposition
2 (address)
W
CC (section) / (tot number) (grave number)
0• Name of Sexton or Person in Charge of Premises h/ °
Z ((tease print)
w (eWjAZ
Signature Title
DOH-1555(07/18)p 1 of 2
r
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#