Evans, Elouise .�, li
NEW YORKSTATE DEPARTMENT OF HEALTH 327
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Elouise Evans Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/01/2021 96 Years War or Dates
1— Place of Death Hospital,Institution or
WCity,Town or Village Warrensburg Town Street Address 273 River Street,Warrensburg Town, New York 12885
p Manner of Death outjNatural Cause 0 Accident Homicide 0 Suicide 0 Undetermined El Pending
W
C.) Circumstances Investigation
WW Medical Certifier Name Title
0
Janine Gadjo NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 11
ElBurial Date Cemetery,Crematory or Facility Name
04/06/2021 Pine View Crematory
Ei Entombment Address
lCremation Queensbury Town,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
pN Hold Address
N �Transportation
Date Point of
a by Common Shipment
Carrier Destination
EIDisinterment Date Cemetery Address
EIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
IIC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/06/2021 Registrar of Vital Statistics Pamela MGfoyd(ECectronicaltySigned)
(signature)
District Number 5660 Place Warrensburg, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition LI/Ip)tl Place of Disposition jL Lc4-_
2 (address)
W
CO
CC (section) (N number) (grave number)
gName of Sexton or Person in Charge of remises t e. L 3 l tt
z /P/ease p nt/
Signature �� Title (tr''`'L{W
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01.Q. 9 5
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#