Ellis, Arlene # Zi(1
NEW YORKSTATE DEPARTMENT OF HEALTH rBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Arlene Ellis Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/05/2022 72 Years War or Dates
1_, Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death 0 Natural Cause ElActident 0 Homicide ESuicide ❑Undetermined ❑Pending
1/1
V Circumstances Investigation
EMedical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 146
Burial Date Cemetery,Crematory or Facility Name
03/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
.
Donation r
Z❑Removal Date Place Removed
and/or and/or Held
p- Hold Address
0
O. Date Point of
Cl)❑Transportation
b by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment 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
QJ
Q' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/08/2022 Registrar of Vital Statistics Megan.1rolrn(E/ctrantcally,SYgnsd)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:i/
I- FZ Date of Disposition 311 1 22.. Place of Disposition s U� L am_
2 (address)
W
Cl)CC (section) iot numbe{) AA it (grave number)
8 Name of Sexton or Person in Charge of P emises ..cim
1 (please lint) �+
IU Signature Title `�
DOH 1555(018)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#