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Ellis, Barbara NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section :: Name First Middle Last Sex {: Barbara P. Ellis Female :r Date of Death Age If Veteran of U.S. Armed Forces, "jiii April 7, 2016 82 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title r: Susanne Rayeski,MD Address 100 Park Street,Warrensburg,NY 12885 Death Certificate Filed District Number Regisiey�lber '..f:, City, Town or Village Glens Falls 5601 1 xxvv ❑X Burial Date Cemetery or Crematory April 12, 2016 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road Queensbury, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held C and/or Address H Hold to Q Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number :::: Name of Funeral Home Regan Denny Stafford Funeral Home 01443 * ' Address 53 Quaker Road, Queensbury,NY 12804 : : Name of Funeral Firm Making Disposition or to Whom r'? Remains are Shipped, If Other than Above Address 1 Permission is hereby ranted to dispose of the human remains des ribed bo as . i ted. : Date Issued ©y!i 2e1& Registrar of Vital Statistics (sign ture) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition 4/12/16 Place of Disposition Pine View Cemetery, QnPPnChury, Ny 2 (address) N Mohawk 100A 1 IY (section) (lot number) (grave number) pName of Sexton or Person in Charge of Premises Connie L. Goedert W (please print) Signatur / it-it -LcL-P—?-r Title Cemetery Superintendent (over) DOH-1555(02/2004)