Ellis, Daniel Richard • tki.///
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Daniel Richard Ellis Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/07/2022 63 Years War or Dates Marines
Place of Death Hospital,Institution or
2 City,Town or Village Jackson Town Street Address 135 Lewis Hill Lane,Jackson Town,New York 12834
a Manner of Death ❑Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
Ui Medical Certifier Name Title
G James Gariepy Coroner
Address
19 East Broadway,Salem Town,New York 12865
Death Certificate Filed Town Of Jackson District Number Register Number
City,Town or Village 5761 4
Burial Date Cemetery,Crematory or Facility Name
06/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
Removal Date Place Removed
c and/or and/or Held
N Hold Address
0
0. Date Point of
N)ITransportation Shipment
a by Common
', Carrier Destination
Disinterment
Date Cemetery Address
ram.
' •' Reinterment Date Cemetery Address
Wr,
'= Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
,. 407 Bay Rd,Queensbury,New York 12804
� Name of Funeral Firm Making Disposition or to Whom
i:: Remains are Shipped,If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/10/2022 Registrar of Vital Statistics No1Ty son(E(ectronicalrySigtmd)
(signature)
District Number 5761 Place Town Of Jackson
,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,�
�: Date of Disposition �y_�!20Z� }�`; 1`Ly+'1li'7`o Place of Disposition rJ e (J;eu� �
(address))
W
I (section) (lot umber) (grave number)
Name of Sexton or Person in Charge of Premises Alyh/Pni b 1 oD J
/ (please print)
W Signature }� `/ Title nP Ps q9 s-
DOH-1555(o7/18)p t of 2
( � 5 A� 8
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#