Ross, Anthony NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
1-_ Name First Middle Last Sex
Anthony Michael Ross Male
--, Date of Death Age If Veteran of U.S. Armed Forces,
10/30/2018 93 Years War or Dates 1943-1946
I Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
jj Medical Certifier Name Title
is Philip Gera MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 63
Burial Date Cemetery or Crematory
,,, 11/03/2018 Pine View Cemetery
❑Entombment
Address
['Cremation Queensbury Town, New York
Date Place Removed
E.ri❑Removal and/or Held
and/or
HoldID
Address
0 Date Point of
to ❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Is❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
,; 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
aAddress
1
4-4 Permission is hereby granted to dispose of the human remains described above as indicated.
reP
Date Issued 11/01/2018 Registrar of Vital Statistics .,Aimee%lahnney( Tectronica1TySigned
(signature)
District Number 5755 Place Fort Edward. New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
11/ Date of Disposition 1 1 /3/201 dace of Disposition Pine View Cemetery QuePnshury .__,r
t (address)
+'fi Mohican 82—B 1
00 (section) (lot number) (grave number)
CI Name of Se ton or Person in Charge of P emises Connie L. Goedert
(please print)
41)
Signature _ Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)