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Rice, Ellen .c\16....1.") ii 700 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ellen Rice Female Date of Death Age If Veteran of U.S.Armed Forces, 08/25/2023 86 Years War or Dates Place of Death Hospital,Institution or Z W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death 1=1NaturalCause Accident Homicide ESuicide Undetermined Trending W Circumstances Investigation E M ical Certifier Name Title Philip Gara MD Address 3 9 , Edward Town,New York 12828 aBroadwayth Certificate FiledFort Town Of Fort Edward District Number Register Number C ty,Town or Village 5755 73 Burial Date Cemetery,Crematory or Facility Name 08/29/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 O. Date Point of N ETransportation Shipment p by Common Carrier Destination ElDisinterment Date Cemetery Address 1 Reinterment Date Cemetery Address 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 t Remains are Shipped,If Other than Above X Address cc W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/25/2023 Registrar of Vital Statistics Aimee G Mahoney(ECectronicaIty Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- WDate of Disposition 9%Z-ZtZ3 Place of Disposition 4 P. 'Je iJJe ) (t`8yj4A.'fartt/ 2 (address) W CO (section) �,/ (lot number) (grave number) SName of Sexton or Person in Charge Premi es 1\ p40"� L,1.)�'J Z /please print/ W . �.���� Title eri l` Signature /�� A g DOH-1555(07/18)p 1 of 2 ..♦ e 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#