Greenfield, Ellen NEW YORK STATE DEPARTMENT'OF Il'EXLTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ellen Ruth Greenfield Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 14, 2016 96 War or Dates
j Place ath Hospital, Institution or
W. City,'Tow or Village Fo -t' A of Street Address 1330 Pattens Mills Road
W Manner of Death Natural Cause 1=1 Accident ElHomicide El Suicide ❑ Undetermined Pending
.? Circumstances Investigation
W Medical Certifier Name Title
W,
Robert P Reeves_MD.,
Address
Three Irongate'Center Glens Falls, NY 12801 y;
Death icate Filed r District Number RegisterNumber
City, Tow or Village 1"o ,t- A y.n . -6?-63/
❑Burial Date Cemetery or Crematory
December 16, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z r-i Removal and/or Held
• and/or Address
F- Hold
th Date Point of
II El Transportation Shipment
0 by Common Destination
" 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
Imo' Remains are Shipped, If Other than Above
Address
IX
-EL_ Permission is hereby granted to dispose of the human rem i s described above i di,ated.
Date Issued 7
- r��5 Re— istrar of Vital Statistics r. ler re
9�
(signature)
District Number 5Z5-y, Place /ic./..die/ ld sic,Z7
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition 12/16/2016 Place of Disposition Quaker Road Queensbury,NY 12804 Piht:VMA4)lr/6wthiero'
(address)
1.13'
co.''
ie (section) 1 (lo number) (grave number)
O Name of Sexton o o in C arge of Premises '.J in, (i 4,1A L r✓lC—G 4.e-
z'', (please print)
W Signature Title Cre--014,10�
(over)
DOH-1555 (02/2004)