Ellsworth, Trevor 110
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Trevor Paul Ellsworth Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/22/2018 15 years War or Dates
Place of Death Hospital, Institution or
City, Tq (g(%WA( Glens Falls Street Address Platt Street
Manner of Death Natural Cause 0 Accident Ei Homicide El Suicide ElUndetermined ri Pending
Circumstances Investigation
tij Medical Certifier Name Title
O Terry Comeau Coroner
Address
1340 State Rt 9, Lake George, Ny 12845
Death Certificate Filed District Number Register Number
City, TcX(Ot X0 ( Glens Falls 5601 103
❑Burial Date Cemetery or Crematory
❑Entombment 03/01/2018 Pine View Cematory
Address
[Cremation Queensbury, Ny
Date Place Removed
Removal and/or Held
� and/Holdor Address
C Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
N• ElPermit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home 01079
Address
82 Broadway Fort Edward, Ny
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
1r
tU
P:"` Permission is hereby granted to dispose of the human remains described above as indicated.
iE Date Issued 02/26/2018 Registrar of Vital Statistics uJ(A,ua —�^
(signature)
ig District Number 5601 Place Glens Falls)N`J
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Date of Disposition 11 t f ig Place of Disposition e k)1
(address)
w
EC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises l^+t S'°r
2 (pl ase print)
Signature Title (10410ti
(over)
DOH-1555 (02/2004)