Mathews, Ella 4/ai
NEW YORK STATE DEPARTMENT OF HEALTH, ",
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ella E. Mathews Female
Date of Death Age If Veteran of U.S. Armed Forces,
fli 04/20/2014 82 years War or Dates N /A
Place of Death Hospital, Institution or
Z City, "D( XorXXp Poughkeepsie Street Address The Pines@ Poughkeepsie
` Manner of Death®Natural Cause D Accident El Homicide 0 Suicide _Undetermined 0 Pending
tii Circumstances Investigation
at Medical Certifier Name Title
0 Maria Noa- Levito F N P - B C
Address
100 Franklin Street, Poughkeepsie, N Y 12601
ig Death Certificate Filed District Number Register Number
iEsi City, 'DtXAXAO.Xdrai Poughkeepsie 1302 330
0Burial Date Cemetery or Crematory
04/22/2014 Pine View Crematory
_Entombment plEpremation Queensbury, N Y
Date Place Removed .,,, , ::
Z El❑Removal and/or Held
and/or Address
I= Hold
tO
0 Date Point of
1)5 0 Transportation Shipment
0 by Common Destination
ig Carrier
Disinterment Date Cemetery Address
ki I:El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Ri Address
24 Church Street, Lake Luzerne. N Y
Iiii Name of Funeral Firm Making Disposition or to Whom
14:_Remains are Shipped, If Other than Above
2 Address
w
Permission is hereby granted to dispose of the human remains described b e as indicated.
<> Date Issued 04/21/2014 Registrar of Vital Statistics r .C-t 6•01-1
(signature)
District Number 1302 Place City of Poughkeepsie
F-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI U Ca Date of Disposition LI/23l1� Place of Disposition ,a u., , ry...
2 (address)
ILI
tgt
CC (section) (lot number) (grave number)
0
CI Name of Sexton or Person in Charge of Premises df,:;11fitie 3ch+ilt
.2 D (please print)
Signature /L. Title CaMAI &
(over)
DOH-1555 (02/2004)