Ross, Charles Washock f . ) 5186086737 71
NEW YORK STATE DEPARTMENT OF HEALTH . Burial - Transit Permit
Vital Records Section
Name First Middle Last ' Sex
- CHARLES L. ROSS , MALE
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2016 62 War or Dates • NO
I-. Place of Death , Hospital,Institution
Z City ,Town or Village City of Albany or Street Address ST. PETERS HOSPITAL
rat Manner of Death Natural Undetermined Pending
® 0 Accident ❑ Homicide ❑ Suicide ❑ ❑
11J� Cause Circumstances Investigation
Medical Certifier Name Title
aI THEA DALFINO MD _
Address
315 S MANNING BLVD ALBANY NY 12208
Death Certificate Filed District Number 1 RegisterNumber
City,Town or Village City of Albany , 101 • , 1 17
Date Cemetery or Crematory
0 Burial 05/26/2016 PINEVIEW CREMATORY
. ❑ Entombment Address
® Cremation QUEENSBURY NY
. Date Place Removed
Z Removal and/or Held
0: ❑ and/or Address
H Hold
CO .
Q Date Point of
p Transportation Shipment
Cl) ❑ By Common O Carrier Destination
❑ Disinterment Date Cemetery Address
❑ ' Date Cemetery Address
Reinterment
Permit Issued To Registration Number
_ Name of Funeral Home ALEXANDER BAKER FUNERAL HOME _ 00037
Address
3809 MAIN ST.WARRENSBURGH NY 12885
Name of Funeral Firm Making Disposition or to Whom
f" Remains are Shipped, If Other than Above
Address
fX
W
, Permission Is hereby granted to dispose of the human remains described above as indicated.
Date 05/25J2016 Registrar of Vital Statistics
Issued
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with thisth7 permit on:
.z Date of Disposition 5J Z 1( , _ Place of Disposition gio t-.r C"-4(G--
w (address)
a
tlI
0)
IX
0 (section) „7(lot number) (grave number)
C`
wName of Sexton or Person in Charge of Premises 1rt31 L'y(
/gyp (please print)
Signature (�� Title atU"414
(over)
DOH-1555(02/2004)