Jackiwski, Ellen Marie 4E)NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ellen Marie Jackowski Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/27/2022 63 Years War or Dates
i- Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
p Manner of Death E1 Natural Cause Accident Homicide DSuicide Undetermined Pending
UJ U Circumstances Investigation
W Medical Certifier Name Title
0 Mathew Varughese DO
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 241
X Burial Date Cemetery,Crematory or Facility Name
_ 05/04/2022 Mount Herman Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
CI. Date Point of
CO❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
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
U7
Ct' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/02/2022 Registrar of Vital Statistics .Megan Wolin(ECectronicalTySigned)
(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—
Z Date of Disposition 5. 41-& Place of Disposition j,U i RnG Ra c Ci s 6u r/ NY J�0
UJ (address)
UJ -ficTi- 1- e 2rn , %R i», lI rPki'
(I)CC (lot number) ) (grave number)
S zName of Sexton or Pe n in Charge of Pm es LY]r�i
ac
W � 6-0.4. C (ppllea�sepprinntt/),[,
Signature Title CI-, t n �-+��^-r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012910
Receipt
Human remains of ! delivered on , 20
Pine View Cemetery Representingrthe funeral home named on burial permit
Official Funeral Directors Reg.or License#
JACKOWSKI ([7—j )
�
NAME Ellen Marie Jackowski Age: 63
Lot Owner: Family Plot
Lot# Mt Hermon Grave#
Case: Concrete
Died: 4.2 7 .2 2 Interred: 5.4.2 2
Funeral Home: Baker FH
Cemetery: MT Hermon