Ross, John NEW YORK STATE DEPARTMENT OF HEALTH / i
Vital Records Section '\. Burial - Transit Permit
'' Name First Middle �,* Last Sex
John Alves Ross Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/22/2006 77 years War or Dates 1g51-53
.14 Place of Death Hospital, Institution or
City, Cfp'rM{
Town � g�1XX�XX City Of Glens Falls Street Address Glens Falls Hospital
0 Manner of Death®Natural Cause 0 Accident Homicide Suicide Undetermined Pending
ua Circumstances Investigation
:w Medical Certifier Name Title
a David Foote M. D.
Addrea Main Street Hudson Falls, N Y 1283g
Death Certificate Filed District Number Register Number
City, Town (Hig6XXXX City Of Glens Falls 5801 127
[]Burial Date Cemetery or Crematory
03/24/2006 Pine View Crematorium
❑Fa,ntombment Address
Cremation 4ueensbury, NY 12804
Date Place Removed
9❑Removal and/or Held
and/or Address�
Cl
Hold
0 Date Point of
85 El Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Robert M. King Funeral Home Number
Name of Funeral Home
Address_Mi Zhurch Street Granville, NY 12832
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
c
tij
Permission is hereby granted to dispose of the human remains desc ibedabove incl.s in ' e .
is Date Issued 03/2d/2008 Registrar of Vital Statisticsha—
��
(signature)
District Number 5,60/ Place 6 Le,„,s .F� I ) S , I y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3-2,y-bi Place of Disposition Aj-i l� kit r0 G R k::: -1-UP\ 1 1(,/1-1,
(address)
UI
O
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C iot \2.t / CyR.z (please print)
Signature E -Q.A4, G_A ,4t4 Title 1� �/� c Z__.
(over)
DOH-1555 (02/2004)