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Ellsworth, Agnes Elmira k yo/ 1.s NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Agnes Elmira Ellsworth Female Date of Death Age If Veteran of U.S.Armed Forces, 06/19/2023 99 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing ILI p Manner of Death Ei Natural Cause Accident Homicide Suicide Undetermined ❑Pending Ill V I—ICircumstances Investigation W Medical Certifier Name Title p Joshua Starteri NP Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed Village Of Granville District Number Register Number City,Town or Village 4725 25 Burial Date Cemetery,t"_reinatorynrFacility Name 06/22/2023 Pine view crematory Entombment Address ©Cremation Queensbury Town,New York Donation • 0❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 n. Date Point of N❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address Disinterment OReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above N Address CC W CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/22/2023 Registrar of Vital Statistics rDianaScarlotta(/ctronicaf Srgnerl) (signature) District Number 5725 Place Village Of Granville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition tc IZIr 173 Place of Disposition ti, IL address) W NCe (section) 1 (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises - (please print) Z W Signature Title `key '.t K''( DOH-1555(07/18)p 1 of 2 R1.. 0 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#