Jackowski, Ellen Marie `'- - LF
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
F- Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑X Natural Cause Accident 0 Homicide 0Suicide Undetermined Pending
ILI
U Circumstances Investigation
GMedical Certifier Name Title
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
ZZ❑Removal Date Place Removed
and/or and/or Held
lF- Hold Address
U)
0
IL Date Point of
to❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
F. Remains are Shipped,If Other than Above
2 Address
CC
Ill
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/02/2022 Registrar of Vital Statistics Megan Nolin(cECectronica/IySigned)
l(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:
F-
Z Date of Disposition 5 41•as Place of Disposition Lu ZCR/X, R6 Q U cr s bo r iV,J /0 0 4l
(address/ 1/
N -r^i77L fie em�Tr /-!a im 2idi-
Q (section) (lot number)l (grave number)
GName of Sexton or Pe n in Charge of P m. es C1 r ni . VAC I2.�"
Z p 4 C (please print)
�
W Signature K• Title JV i !>7eK ./7I.
DOH-t555(o7/18)p 1 of 2
Public Healxh Law Sec. 4145(2b)
012910
Receipt
Human remains of ! delivered on , 20
O, r
J r �f` „ _•- --
/ . _ f / .
Ping View Cemetery /Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
JACKOWSKI
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
Jackowski
Owner
Family Plot
Address Plot
MT HERMON 1 "
Phone # Lot #
Deed # Date
Cost Foundation Y - N
Location
MT HERMON
Remarks
Record of Interments ,
a
1
M