Ellis, Eva t /to
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eva Anne Ellis Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/09/2017 86 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Carrie Miron PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 155
❑Burial Date Cemetery or Crematory
12/12/2017 Pine View Crematory
El Entombment Address
®Cremation Queensbury, New York
Date Place Removed
El❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/11/2017 Registrar of Vital Statistics Carohne If Bar6er 'ECectronicaaySigned'
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /t l2Ill Place of Disposition ;, r
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 5 .4t{
(p ase print)
Signature ! /L u Title (k6-1►M1)J,2_
(over)
DOH-1555 (02/2004)