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NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ellen And Strain Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/14/2022 95 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 187 E Schroon River Road,Lake George Town,New York 12824
Manner of Death El Natural Cause DAccident 0 Homicide OSuicide r1Undetermined Erending
W
V Circumstances Investigation
CMedical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Oueensbury Town,New York 12804
Death Certificate Filed Town Of Lake George District Number Register Number
Cit E,Town or Village 5651 16
Burial Date Cemetery,Crematory or Facility Name
08/16/2022 Pine View Crematory
Entombment Address
Cremation Oueensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
O
4. Date Point of
to ElTransportation
p by Common Shipment
Carrier Destination
-
Disinterment
Date Cemetery Address
'ElDate Cemetery Address
Re interment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/16/2022 Registrar of Vital Statistics Pates4tAtclntsay-Sclurster('F.lar Srynst4
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 9 (1 lit Place of Disposition AIL
2 (address)
W
U)
Q (section) I (lot number) &'� (grave number)
tt
G Name of Sexton or Person in Charge emises �4ease
�" ��
Z print)
W Signature Title co6A Tx
DOH-1555(o7/18)p i of 2
I
IPublic Health Law Sec. 4145(2b)
1
1 Receipt
i
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#