Guzman-Lopez, Ella ` P ,oc
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last t unman La peL Sex
Ella Marie -Ma aha,7.1 Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 / 20 / 2017 lhr 59min War or Dates N/A
Place of Death Hospital, Institution or
ZCity, Town or Village Albany Street Address Albany Medical Center
a Manner of Death®Natural Cause Accident 0 Homicide �Suicide Undetermined 7 Pending
W. Circumstances Investigation
la Medical Certifier Name Title
0 Alyse S. Blanchette MD
Address
43 New Scotland Ave, Albany, NY 12208
>>> Death Certificate Filed District Number 010 Register N mber
City, Town or Village Albany 9
p.i.ElBurial Date CemeteryCrematory
/��/ ��� or Pine View Crematory
0 Entombment Address
i E Cremation Queensbury, NY
Date Place Removed
4❑Removal and/or Held
and/or
B Address
Hold
W. Date Point of
aiQ Transportation Shipment
a by Common Destination
Carrier
111
Q Disinterment Date Cemetery Address
oi Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. , Saratoga Sp., NY 12866
.' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /2.2 Ill Registrar of Vital Statistics )o l l i l I I l G) i i c i C, k�
(signature)
District Number di 0, ' Place Albany , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I//tilr) Disposition �?.,li... ` ��';4...,
p Place of
(address)
til
VA
ir (section) 4, (lot number) (grave number)
II Name of Sexton or Person in Charge of Premises hn• Sa�.tt*
2 •
�/, D please print) •
Signature �:( �-+RS' Title tiZEAVIA
•
(over)
DOH-1555 (02/2004)