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Meyerhoff, Ellen NEW YORK STATE DEPARTMENT OF HEALTH ,. -` A&3 Vital Records Section Burial - Transit Permit Name First Middle -- Last Sex Ellen Janet Meyerhoff Female Date of Death Age If U.S. Armed Forces, July 1, 2018 77 Vs tar or> s Place of Death Hosi. LQ', institution or w City, Town or Village Moreau Street Address 24 Cashmere Drive Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending US 0 Circumstances Investigation tii Medical Certifier Name Title Darci Ann Gaiotti-Grubbs, M.D Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed Distric er Regi, r fy,umber City, Town or Village Moreau ,D( ❑Burial Date Cemetery or Crematory July 2, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of 1-, ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission piss h reby granted to dispose of the human remains scribed boy as indicated. Date Issuedv/ O� /$ Registrar of Vital Statistics (signature District Number C. �-- Place I/q o1Q. , /u. y. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i :' Date of Disposition 07/02/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises L ir4tri.. SO4'4t (pl ase print) LU Signature4 Title !'¢41P1l, (over) DOH-1555 (02/2004)