Ross, Max NEW YORK STATE DEPARTMENT OF HEALTH 4>0/
Vital Records Section ` itBurial - Transit Permit
;' Name First Middle Last Sex
Max O. Ross Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 25,2017 65 War or Dates
. r Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 13 Carey Road
z Manner of Death X Natural Cause Accident n Homicide Suicide n Undetermined Pending
a Circumstances Investigation
w Medical Certifier Name Title
0 Michael R.Bell
Address
'' HHEIN,Warrensburg,NY 12885
_ Death Certificate Filed District Number Register Number
11:'` City, Town or Village Lake George 5651
❑Burial Date Cemetery or Crematory
December 28,2017 Pine View Crematory
El Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
77
Permit Issued to Registration Number
.
Name of Funeral Home Alexander-Baker Funeral Home 00037
eAddress
3809 Main Street,Warrensburg,NY 12885
F: Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
$. Address
16
Permission is hereby granted to dispose of the human remains described above as indicate
Date Issued l ' (- f Registrar of Vital Statisti 1( �'�r1s�—ee" �
(sign re)
District Number 5651 Place :� "..6 )42,1 Gd_C
.„
, „,__
I certify that the remains of the decedent identified above were disposed of in cc rdance with this permit on:
Z r
wDate of Disposition )2/24 f/1 Place of Disposition )9,31 _u1&) / rre.,.,, toy
W l / (address)
U)
IX (section) (lot numb r) (grave number)
QName of Sexton or P n Ch rge of Premises J (,c N a evi ctc,i 2
'Z (please print)
Signature Title G e ✓n )0/
(over)
DOH-1555 (02/2004)