Ellis, Shirley NEW YORK STATE DEPARTMENT OF HEALTH 1
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley I. Ellis Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/13/2014 95 years War or Dates
i-. Place of Death Hospital, Institution or
Z City, Tov /i ( Glens Falls Street Address Glens Falls Hospital
W Manner of Death k,aatural Cause ❑Accident ❑Homicide ElSuicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Suzanne M. Rayeski M.D.
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Tov)O(g MR100(X Glens Falls 5601 186 -
❑Burial Date Cemetery or Crematory
❑Entombment 04/14/2014 Pine View Cemetery
Address
MQremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
21-j and/or Address
Hold
10
O Date Point of
i E Transportation Shipment
25 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
I. Remains are Shipped, If Other than Above
2 Address
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a.
Permission is hereby granted to dispose of the human remains describe above as .ndi
Date Issued 04/14/2014 Registrar of Vital Statistics ‘41
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition goislrl Place of Disposition �,fi? CAD(v_
2 (address)
ill
lC (section) d
(lot number (grave number)
ci Name of Sexton or Pers n in Charge f Premises 0 1 3it✓l'
(p/l?ase print)
ILI
Signature /1/ Title G
--9 (over)
DOH-1555 (02/2004)