Mattison Sr., Ellis Leonard )3>ll'
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ellis Leonard Mattison Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2020 82 Years War or Dates 1955-1957
F.. Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
W• Manner of Death Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Carl Beckler MD
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5756 81
Burial Date Cemetery,Crematory or Facility Name
12/21/2020 Pine View Crematory
Entombment — --
Address
ElCremation Queensbury Town,New York
ElDonation
O Removal Date Place Removed
and/or and/or Held
Hold Address
O
EL Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
EIDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward, New York 12828
Name of Funeral Firm Making Disposition or to Whom
H. Remains are Shipped,If Other than Above
22 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/21/2020 Registrar of Vital Statistics jenny Linda Ifartelle(ECectronicalry Signed)
(signature)
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �.J Lre rn4?6 P
W Date of Disposition �2-2/,�� Place of Disposition , .lhetJ
(addres)
W
CC (section) I (lot number) (grave number)
O▪ Name of Sexton or Perso harge of Pre ' s b� 1 f o".'! t4G
/please print/ y� "
W Signature Title Z-e7-- 44 �gi
DOH-1555(07/18)p t f 2
Public Health Law Sec. 4145(2b) 014306
Receipt
Human remains of delivered on a , 20
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#