Gross, Walter NEW YORK STATE DEPARTMENT OF HEALTH
i 't #A0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Walter Gross Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/07/9014 84 years War or Dates
Place of Death Hospital, Institution or
li City, TowRza(il (X Glens Falls Street Address Glans Falls Hospital
Manner of Death EI N tural Cause Accident Homicide Suicide Undetermined Pending
W k� Circumstances Investigation
't Medical Certifier Name Title
CZ Glen Anderson M D
Address
61 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Towm yilintxx Glans Falls 5501 110
❑Burial Date Cemetery or Crematory
❑Entombment 0'1/10/2014 Pine View Crematorium
Address
-Ciyemation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9.❑and/or Hold Address
ul
O Date Point of
NQ Transportation Shipment
d by Common Destination
Carrier
::>: Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. Permit Issued to Registration Number
Name of Funeral Home Levine Mermorial Chapel 01035
>` Address
649 Washington Ave Albany, NY 12206
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
II' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ` 03/10/2014 Registrar of Vital Statistics C'`.V)- -.s (A). -LA-
(sig ature)
District Number Place N y,
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ill Date of Disposition .3iiif rf Place of Disposition Zov;Aw aelot
(address)
W
U
tr (section) (lot numb (grave number)
• Name of Sexton or Person - Charge of P mises it,406, 3r44
/(please pant)
Signature L Title cricow
•
(over)
DOH-1555 (02/2004)