Ellsworth, Betty L # zgZ
NEW YORK STATE DEPARTMENT OF HEALTH tr Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Betty L.Ellsworth Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2022 92 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Albany Street Address Hudson Park Rehabilitation And Nursing Center
p Manner of Death El Natural Cause Accident Homicide ESuicide Undetermined ❑Pending
VCircumstances Investigation
QW Medical Certifier Name Title
Ada Nnabugwu NP
Address
325 Northern Blvd,Albany,New York 12204
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 0798
BurialEd
Date Cemetery,Crematory or Facility Name
04/01/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
E- Hold Address
N
0
O. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/01/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WF t�� 6�.,
Date of Disposition �I lZ Place of Disposition
2 (address)
W
to
Q (section) (lot number) c (grave number)
GName of Sexton or Person in Charge remises "� � � ��tr i .-1f14
Z please print/ /�,�
Ill *NOWTitle G r"'��
DOH-1555(07/18)pi 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#