Ehle, Stormi Mykah-Annette Hat
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stormi Mykah-Annette Ehle Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/11/2020 5 Days War or Dates
i.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death ❑ Natural Cause ❑Accident El Homicide ❑Suicide 0 Undetermined Pending
U Circumstances Investigation
WQ Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 510
Burial Date Cemetery,Crematory or Facility Name
11/13/2020 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
0 ElRemoval Date Place Removed
and/or and/or Held
- Hold Address
O
4. Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg, New York 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/12/2020 Registrar of Vital Statistics cRpbertAndrew Curtis(ECectronicalry Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /1���-
F- L,i r
Date of Disposition I i nib Place of Disposition
2 address)
W
CC CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises tJ 1. ✓,DN 1T
z (plese print)
gSi nature -'�'�+ Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 4 " 1.,it 1 C1 2
Receipt
Human remains of delivered on , 20
/ ✓/ /
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#