Ciezenski, Ellen -
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.- Name First Middle Last Sex
Ellen I. Ciezenski Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 21,2016 73 War or Dates NA
Place of Death Hospital, Institution or
• City, Town or Village Town of Queensbury Street Address 1040 West Mountain Rd.
Manner of Death g Natural Cause n Accident n Homicide n Suicide Undetermined Pending
{ Circumstances Investigation
'. Medical Certifier Name Title
Eric Pillemer MD
Address
100 Park St.Glens Falls,NY 12801
4 Death Certificate Filed Di ct Number RegisterrThimber
City, Town or Village Town of Queensbury,NY �(gsl t S :
❑Burial Date Cemetery or Crematory
November 25, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
tO
0', Date Point of
N?❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
{ Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
• 53 uaker Road ueensbur ,NY 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 ve aV indicated.
n
Date Issued I 1 �,`f 1pRegistrar of Vital Statistics - _ �-C
1 (signature)
pi District Number L5c") Place I 6 1_,_...Th --)--(. �- l„
0.
I certify that the remains of the decedent identified above were disposed of in accorda ce wit this permit on:
z n
W di,:Date of Disposition !jj"Z$IIL. Place of Disposition U,,.w f'elli a,,.-
(address)
CO
W. (section) (lot number) (grave number)
/
00 Name of Sexton or Person in Charge of Premises `/s .SPAl
Z ( lease print)
W Signature of 9 Title r '� C,
(over)
DOH-1555(02/2004)