Ellsworth, Mary NEW YORK STATE DEPARTMENT OF HEALTH a ,; et1:3
Vital Records Section Burial - Transit Permit
tiii Name First Middle Last Sex
00. Mary Elizabeth Ellsworth Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 19, 2017 88 War or Dates
Place of Death Hospital, Institution or
ut City, Town or Village Glens Falls Street Address
tifM• anner of Death mil Natural Cause Accident El Homicide Suicide riUndetermined El Pending
iqt Circumstances Investigation
Lit M• edical Certifier Name Title
Patricia Auer,
Address
41,
Queenbury Hudson Headwaters, 12894
Death Certificate Filed District Number Register Number
City, Town or Village 5601 J77,
• ❑Burial Date Cemetery or Crematory
March 22, 2017 Pine View Cremat m
Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
4.4k ❑Transportation Shipment
by Common Destination
C:' Carrier
Disinterment Date Cemetery Address
Reinterment 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
'__K Remains are Shipped, If Other than Above
Address
144
�t, Permission is hereby granted to dispose of the human remains described above as indicated.
- -• - Date Issued 3>22/ 1 -, Registrar of Vital Statistics l f .9 1 3 `",�;CA.A. y , A.
(signature)
District Number 5601 Place 6 �`^s Fu\\s fU
„,,,,,,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iti Date of Disposition 03/22/2017 Place of Disposition Quaker Road Queensbury,NY 12804 ?they`.) ,c,f
(address)
ilk
NY
c (section) ` (lot number) (grave number)
Name of Sexton -P n Charge of Premises /AI/ ✓t 6a--v✓C�G4.
(p/ease pri t)
Signature ',,A- Title C 6.- r
/ (over)
DOH-1555 (02/2004)