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Ellis, Debora NEW YORK STATE DEPARTMENT OF HEALTH ' 4 - 324 Vital Records Section : Urial - Transit Permit ' Name First Midd ast Sex Debora Marie Female Date of Death Age If Vetera Armed Forces, April 22, 2017 60 War or Dates of Death Hospital, Institution or 111,, own or Village Glens Falls Street Address Glens Falls Hospital anner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending LI Circumstances Investigation �l Medical Certifier Name Title G' ; Michael Miles, M.D 2i Address '� 100 Park Street Glens Falls, NY 12801 h Certificate Filed / District Number Register Number own or Village -y I n s -I 1 s , 5601 23) 47 1.❑Burial Date Cemetery or Crematory April 24, 2 0.7a Pine View Crematorium F,❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ,-- Date Place Removed z ❑ Removal and/or Held and/or Address Hold St. Paul's Cemetery Date Point of ❑Transportation Shipment S by Common Destination Carrier €E Date Cemetery Address ❑ Disinterment 3 ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number 01, Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above 2 Address a: .w' p.__ Permission is her by ranted to dispose of the human 4mains scribed ove as in cate . E Date Issued Registrar of Vital Statistics liir7 7 ‹ (signature) District Number 5601 Place .2 d., rs ��<-,—Y47 ,07-) (// I certify that the remains of the decedent identified above were disposed of in accorda a with this permit on: h Date of Disposition 04/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) a ro (section) (lot number) (grave number) i Name of Sexton or Person in Charge o, Premises / t. � �+�� Z (pl ase print)i W Signature L1 �_ Title 1"'o �2 (over) DOH-1555 (02/2004)