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Ross, Myrtle NEW YORK STATE DEPARTMENT OF HEALTH E F # q1111 Vital Records Section Burial - Transit Permit f, Name First Middle Last Sex Myrtle M. Ross Female • Date of Death Age If Veteran of U.S. Armed Forces, July 10,2014 89 War or Dates • Place of Death Hospital, Institution or -Za City, Town or Village Glens Falls Street Address Glens Falls Hospital s Manner of Death n Natural Cause n Accident Homicide n Suicide n Undetermined Pending Circumstances Investigation ;w: Medical Certifier Name Title C: Suzanne M.Blood Address 14 Manor Drive,Queensbury,NY 12804 • Death Certificate Filed District Number Register Number -,_' City, Town or Village Glens Falls 5601 2 2'7 ❑Burial Date Cemetery or Crematory 11 Entombment July 11,2014 Pine View Crematory Address ©Cremation Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address Hold Cl) O Date Point of O. n Transportation Shipment p by Common Destination Carrier Li Disinterment Date Cemetery Address Reinterment Date Cemetery Address k$=- Permit Issued to Registration Number =f Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 4 3809 Main Street, Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Address ra s Permission is hereby granted to dispose of the human remains described above as indicated. ' Date Issued ) ) 1 I 1 I I-) Registrar of Vital Statistics Q,l� _ Vv v4 ( (signature) y= District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z w Date of Disposition 1-1c'iy Place of Disposition f4J �,�.-viaTl1.-- E (address) w U) (section) (lot numb (grave number) Z Name of Sexton or Person in Charge of Premises int49.- W (please print) Signature1..1- /_ Title cminijr f f (over) DOH-1555 (02/2004)