Jones, Ella 71
NEW YORK STATE DEPARTMENT OF HEALTH �'-' 7iZ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ella Violet Jones Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 14, 2015 90 War or Dates
I— Place of Death Hospital, Institution or
uj W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Q Manner of Death X❑ Natural Cause❑ Accident ❑'Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
O Dr. Sean Bain,
Address
Death Certificate Filed District Number Register Number
City, Town or Village 5601 L -Ore
❑Burial Date Cemetery or Crematory
October 16, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
I•- Hold
N Date Point of
a. ❑Transportation Shipment
0 by Common Destination
a Carrier
Date Cemetery Address
n Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
M Address
CL
• Permission is hereby granted to dispose of the human remains de,scribed ab e a aGated.
Date Issued /O ��,/2 / Registrar of Vital Statistics 24 d
/
(signature)
District Number 5601 Place 6,ei,.o ,`7 /0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W? Date of Disposition 10/16/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2' (address)
W
CO
I (section) it., (lot number)c (grave number)
a Name of Sexton or Person in Charge f Premises s S[a
Z> 1 (please print)
LU Signature 14 Title
(over)
DOH-1555 (02/2004)