Gauvin, Ella Pauline . . . .4 gb
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ella Pauline Gauvin Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/09/2021 91 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Long Lake Town Street Address 143 Burketowne 2nd Avenue,Long Lake Town,New York 12847
W Manner of Death Undetermined 0 Pending
0 � Natural Cause �Accident �Homicide �Suicide
LU C.) Circumstances Investigation
IL! Medical Certifier Name Title
CI Michael Bell MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Long Lake 2056 2
ElBurial Date Cemetery,Crematory or Facility Name
02/16/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
El Donation
Z Removal Date Place Removed
and/or and/or Held
f- Hold Address
U)
0
O. i—iDate Point of
coLi Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/16/2021 Registrar of Vital Statistics Dit1'QLee Le6lanc(Electronical5141ae4
(signature)
District Number 2056 Place Long Lake, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 2 jig Ill Place of Disposition .0"IL �4-o--
LU
2. (address)
W
CO (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises �A 1 — ��n.�t'�
z
G /P!e a print)
W Signature /� Title �� ��
DOH-1555(07/18)p 1 of 2
. �
Public Health Law Sec. 4145(2b) 014547
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#