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OBrien, Patrick L ter'-----,\ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Patrick L OBrien Male Date of Death Age If Veteran of U.S.Armed Forces, 08/21/2023 74 Years War or Dates i_ Place of Death Hospital,Institution or WCity,Town or Village Long Lake Town Street Address 271 Kickerville Lane, Long Lake Town, New York 12847 p Manner of Death Natural Cause Accident ❑Homicide 0Suicide ❑Undetermined riPending ILC.) Circumstances Investigation LU Medical Certifier Name Title CI Carl Turner Coroner Address 1188 Main Street, Long Lake Hamlet,New York 12847 Death Certificate Filed Town Of Long Lake District Number Register Number City,Town or Village 2056 4 Burial Date Cemetery,Crematory or Facility Name 08/24/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address U) 0 d. Date Point of Cl) Transportation p by Common Shipment Carrier Destination 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 5 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/24/2023 Registrar of Vital Statistics Dixie Lee Leblanc(Electronically Signed) (signature) District Number 2056 Place Town Of Long Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H WDate of Disposition g I7S'it; Place of Disposition r„.1.._2 ess) W Cl) 0 Q (section) ` '' lot number) .`✓tuv' (grave number) Name of Sexton or Person in Charge of Premises • �t.,Z /pint/ W Signature g Title ���J1tNo' .a DOH-1555(07/18)p 1 of 2 1 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#