Ellsworth, Bruce NEW YORK STATE DEPARTMENT OF HEALTH
310
Vital Records Section Burial - Transit Permit
70: Name First Middle Last Sex
Bruce Ellsworth Male
1Date of Death Age If Veteran of U.S. Armed Forces,
May 4, 2015 lD Li War or Dates
'r Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 103 Pleasant Valley Road
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Portuese
Address
t''''4, 100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed Argyle District Number Register Number
ems} City, Town or Village 0 S 7 S 4
❑Burial Date Cemetery or Crematory
May 11, 2015 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
U)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
{;r
r{; Permit Issued to Registration Number
:; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
g Address
; �; 53 Quaker Road, Queensbury,NY 12804
fir, Name of Funeral Firm Making Disposition or to Whom 1: Remains are Shipped, If Other than Above
' Address
;.,r' Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued S 15 115 Registrar of Vital Statistics (signature)
Argyle• District Number 51� S�1 SD Place gY le
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition i ij,,f _ Place of Disposition et,U f�., C ,dam
W (address)
U)
O (section) ii. (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises rti< 34144-
Z �f ( lease print)
W Signature ®L' j, Title filg.sIgigiL
(over)
DOH-1555(02/2004)