Ross, Charlotte - `. #1ZL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charlotte M.Ross Female
„ Date of Death Age If Veteran of U.S.Armed Forces,
09/02/2018 85 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death®Natural Cause 0 Accident ID Homicide El Suicide Undetermined �Pending
Circumstances Investigation
Medical Certifier Name Title
Noelle Stevens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
PktV City, Town or Village Glens Falls 5601 421
❑Burial Date Cemetery or Crematory
09/05/2018 Pine View Crematory
Entombment Address
.®Cremation Queensbury Town, New York
Date Place Removed
_❑Removal and/or Held
} and/or Address
Hold
' Date Point of
y Q Transportation Shipment
by Common Destination
tit Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Ao Name of Funeral Home Maynard D Baker Funeral Home 01130
el Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,
. Permission is hereby granted to dispose of the human remains described above as indicated.
11,
01 Date Issued 09/05/2018 Registrar of Vital Statistics ti6ertA Curtis(ECectronicallySigned)
(signature)
;;.1 District Number 5601 Place Glens Falls, New York
AV I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,
Date of Disposition °) (6(1' Place of Disposition 1204.,., Ktovial Orst_.
(address)
(section) /Jl (lot number) (grave number)
ti
' Name of Sexton or Person in Charge of Pr ises l/ II�t' 'ant)
Title rig ���� �
(p pR
Signature s m -
(over)
DOH-1555 (02/2004)