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Millis, Clifford Mark NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Clifford Mark Millis Male Date of Death Age If Veteran of'1.S.Armed Forces, 02/15/2024 60 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Corinth Town Street Address 199 Howe Road,Corinth Town,New York 12822 IJJ tp Manner of Death El Natural Cause Accident ElHomicide Suicide []Undetermined ri Pending Circumstances Investigation LU Medical Certifier Name Title 0 Eric Borden MD Address 3044 Route 50,Wilton Town,New York 12866 Death Certificate Filed Town Of Corinth District Number Register Number City,Town or Village 4553 8 Burial Date Cemetery,Crematory or Facility Name 02/17/2024 Pineview Crematory _Entombment Address ©Cremation Queensbury Hamlet,New York Donation ZO❑Removal Date Place Removed and/or and/or Held _ H Hold Address 0 d Date Point of U) Transportation by Common Shipment Career Destination ❑Disinterment Date Cemetery Address ElReinterment 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 H Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2024 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: IH ' ` W Date of Disposition 2120124 Place of Disposition =:�wsc.J C(Zf_AVVID U.,-- Z.- (address) W . U) (section) (lot number) stA,4 (grave number) 2 Name of Sexton or Person in Charge of Premi (pi se print) W Signature • Title 1. 11V- DOH-1555(07/18)p i 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 Funeral Directors Reg.or License#