Ross, John IF 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First .(31,-N r. Middle �S�k Last doss Sex M
i
Date of Death Age I If Veteran of U.S. Armed Forces, _
1 Z \ B 1 ZO 11- I CO 1 W r or Dates
H e of Death osptta, nstitution or C�;
W City, own or Village U -- [�-t- - Street ddress "� '�
pManner of Deatiy Natural Cause 0 Accident Homicide Q Suicide 0 Undetermined El Pending
Circumstances Investigation
}j Medical Certifier Name / Title K
CI ! 1 Sal �\\er_
Address
\ C(-ossS—i., \- , I \21\ 14
nth Certificate Filed ; District Number # Register 11 I
ity 'own or Village1 — 1
❑Burial Date V2' 12` ZaI ; Cemetery emato
r1ne, VIQt.v
['Entombment Address •(IF: remation akailLS2. d ) C ms bi.,�.�t.1 1 h.I. 12 scA
Date Place Removed
A Removal and/or and/or Held
M Hold Address
U)
0 ! Date Point of
N Q Transportation I Shipment
a by Common Destination
Carrier
El Disinterment Date ! Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to ! Registration Number
Name of Funeral Home Baker Funeral Home i 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
II- Remains are Shipped, If Other than Above
2 Address _ ..
EL
4. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i21 t.2/20/1 Registrar of Vital Statistics 3CilA1)- 4 \ \L/
(sign re)
District Number S / Place V Cvv\C rA ' I S / K.) Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition al t.j 0 Place of Disposition P IL.A 6-ctoii
(address)
U)
fliX (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premi es Ihr.. Siam
Z (p1 se print)
lti Signature 4� C' Title - [arm_
(over)
DOH-1555 (02/2004)