Ellis, Francine i . . )
NEW YORK STATE DEPARTMENT OF HEALTH ft 117
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francine Marie Ellis Female
1 Date of Death Age If Veteran of U.S. Armed Forces,
June 1, 2017 59 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 10 Elizabeth St.
W Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
a Circumstances Investigation
Medical Certifier Name Title
Colleen Quinn, M.D
Address
9 Carey Rd. �Queensbury, NY 12804
D Certificater Filed (1 j ENS FALLS District Numbet��� RegisteyjV� ber
Ci own or Village 61,G
:° ❑Burial Date Cemetery or Crematory
June 5, 2017 Pine View Crematorium
❑Entombment Address
a®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
7 ❑ Removal and/or Held
and/or Address
Hold
t Date Point of
Transportation Shipment
a/', by Common Destination
C. Carrier
[I] Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
,
', Permit Issued to Registration Number
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
I- Remains are Shipped, If Other than Above
2 Address
Ce
Permission is hereby granted to dispose of the human remains described above al indicated.
Date Issued 6 15 l i 7 Registrar of Vital Statistics C,t_k--).`p. �� --
(signature)
,_ District Number 560 / Place 6 UA.,srick115 J N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 06/05/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
t (section) /,/(lot number) (grave number)
cl Name of Sexton or Person in Charge of Premises G�I(tr� r Spina,z, (pie se print)
Signature ( Title F IlRioII.
(over)
DOH-1555 (02/2004)