Ellis, Douglas f " 2I1?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Douglas A. Ellis Male
iiiig Date of Death Age If Veteran of U.S. Armed Forces,
03/14/2017 72 years War or Dates
: Place of Death Hospital, Institution or
City, T (X ( Glens Falls Street Address Glens Falls Hospital
a Manner of Death I�Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ri❑Pending
W. Circumstances Investigation
tu Medical Certifier Name Title
C Dean A Reali M D
Address
3767 Main Street Warrensburg, N Y 12885
Death Certificate Filed District Number Register Number
City, T MOM%UsX Glens Falls 5601 159
g1111111Burial Date Cemetery or Crematory
03/16/2017 Pine View Cemetery
❑Entombment Address
['Cremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
P and/or
h;; Address
U
Hold
0 Date Point of
OS ❑Transportation Shipment
G! by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
NE 24 Church Street Lake Luzerne, N Y 12846
iiiiiIii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
at
Ili
A. Permission is hereby granted to dispose of the human remains descri a abov as`G 'cated.
Date Issued 03/16/2017 Registrar of Vital Statistics "
(signature)
gi 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:
2
W Date of Disposition 4//�,//7 Place of Disposition �i iCie„-,i'2GL;re,-.J Cre ,may
J // (address) /
W
CA
(section) 1 (lot number) (grave number)
ci Name of Sexton or er on A Charge of Premises v �- /f e;...p ./#-l& 4 '
(please print)
Signature �A Title Gr'z yncL./-cy,-----
(over)
DOH-1555 (02/2004)