Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Ellsworth, Gordon E.
4 733 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Gordon E. Ellsworth Last Sex Date of Death I Male Age If Veteran of U.S.Armed Forces, 03/01/2021 93 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town 1 Street Address Elderwood at North Creek Manner of Death ©Natural Cause VAccident Homicide Suicide 0 Undetermined Pending LU Medical Certifier Circumstances Investigation CI Name Title Madison Zuis NP Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number City,Town or VillageRegister Number North Creek 5655 8 Burial Date Cemetery,Crematory or Facility Name 03/03/2021 Pine View Crematory El Entombment Address ElCremation Queensbury Town,New York Donation 0 EI Removal Date Place Removed r_, and/or and/or Held N Hold Address 0 O. Date Point of to LI Transportation jr) by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom l- Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/02/2021 Registrar of Vital Statistics Kathleen C. Lorah(Electronically Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �I W Date of Disposition 313 1 Z( Place of Disposition t„ lL /j Or (address) W (section) 4 (lot number) (grave number) CC O Name of Sexton or Person in Charge of Premises print) Q (please print/ Z `2"tT W Signature Title 00H-1555(o7h8)p 1 of 2 Public Health Law Sec. 4145(2b) 014604 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#