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Ross, Agnes (2)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Agnes Cecile Ross Female Date of Death Age If Veteran of U.S.Armed Forces, 11/27/2019 1 83 Years War or Dates F. Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Mannerof Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation V W Medical Certifier Name Title G Jennifer Stratton MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 518 ©Burial Date Cemetery,Crematory or Facility Name 12/04/2019 P y Pine View Cemetery -Entombment Address Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or —7and/or Held 0) Hold Address O �. Transportation Date Point of (A � Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/02/2019 Registrar of Vital Statistics WQp6ertf3ndbew Curt&(E§ctron,;wR Srgned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 1 a-" -1 Place of Disposition op/ c/ Q BLS cYV `d W (address) W 7 CO) (section/ (lot number) (grave number) O Name of Sext r Person in Chan Premises (please print) W Signature Title DOH-1555(07/1 )p 1 of 2 P I 1 Public Health Law Sec. 4145(2b) 6 _ U1035.5 _ Receipt { Human remains.of delivered ep+, - , 20_ Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#J'