Baker, Ella NEW YORK STATE DEPARTMENT OF HEALTH f rig
i z3 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ella Baker Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 16, 2011 91 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
IIS Circumstances Investigation
at Medical Certifier Name Title
Q3 Amy Hogan-Moulton,MD
Address
2 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village GLens Falls 5601 c/
❑Burial Date Cemetery or Crematory
October 18, 2011 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9 and/or Address
F" Hold
N
0 Date Point of
NTransportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
%- Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
M' Remains are Shipped, If Other than Above
5 Address
tC
W
d Permission is hereby granted to dispose of the human remains describ d above s in II�' ed.
Date Issuedl0 l D l/ 8 o20 Registrar of Vital Statistics /� �
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-
(signature)
District Number 5601 Place GLens Falls /,)y /c 7I
I certify that the remains of the decedent identified above were dis osed of in accordance with this permit on:
W Date of �It
iq O Disposition Place of Disposition [ ,r4QUttw Cri/Th �0rti,
P I �
2 (address)
W
CO (section) (lot number) (grave number)
p Name of Sexton or Per n in Charge Premises 4,;st,T14, Je,nd lZ i-,
please print)
W Title C t2 E rn 0�
Signature ?IL—
(over)
DOH-1555(02/2004)