Ellithorpe Jr, Edward NEW YORK STATE DEPARTMENT OF HEALTH — /' 76g
Vital Records Section f Burial - Transit Permit
Name First Middle Last Sex
Edward Gordon Ellithorpe Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 5, 2015 84 War or Dates Korea
I. Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
o Manner of Death X❑ Natural Cause ❑ Accident El Homicide El Suicide III Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Jennifer Donovan, D.O.
_Address
/O 4-- .e t, Gfe-nc ,lts w / /2 O1
Death Certificate Filed District Number 500 i Register Number i a l
City, Town or Village
❑Burial Date Cemetery or Creme*-"•
April 9, 2015 Pine View‹rear+cf e.t i
„j❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Z.❑ Removal and/or Held
43 and/or Address
H Hold Moss Street Cemetery
(.0' Date Point of
eL ❑Transportation Shipment
a/) by Common Destination
5 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
F Remains are Shipped, If Other than Above
E Address
CC
a Permission is he eby granted to dispose of the human ' s scribed a ove as ind'
cL Registrar of Vital Statistics ,
Date Issued ®d�,�r 7( 9 �l�Q�. / Gi`-C.
(signature)
District Number : / Place
���
I-. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W', Date of Disposition 04/09/2015 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 (address)
W
U?"
W (section) i (lot number) (grave number)
pName of Sexton or Person in Charge of Premises G^E - r,"t`
Z / (please print)
WSignature A-_ Title aRk t?kI
(over)
DOH-1555 (02/2004)