Ross, Lisa NEW YORK STATE DEPARTMENT OF HEALTH * it L l y
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lisa Lynn Ross Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/ 2012 53 years War or Dates
=- Place o eath Hospital, Institution or
X ity Tow Vl - Street Address
114 • Glens Fa ParktiggeFtainNeSner atural Cause Li Accident ❑Homicide ❑Suicide Pending
LSE Circumstances Investigation
in Medical Certifier Name Title
0
Addresel A. Gillani M D
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
OV it oCCV X Clcns Falls 5601 537
❑Burial a e Cemetery or Crematory
❑Entombment Address 1/26/2012 Pinc Vicw Crcmatory
[ fremation Queensbury, NY
Date Place Removed
i ❑Removal and/or Held
and/or Address
F= Hold
in
0 Date Point of
gt Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcnx& Regan Funeral Hoi71e- 01821
Address
•
11 Algonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
til
Permission is hereby granted to dispose of the huma remain escribed ove as ind'
Iplii Date Issued 11/26/2012 Registrar of Vital Statistics ei�_e_,r L72 12 (._
(signature)
District Number Place /A-FT1C
5601 Glens Falls /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition if iiw iL Place of Disposition ZUtt.,) ` torIv_.
(address)
ILEA
0
CC (section) (lot numbed'` (grave number)
Name of Sexton or Person in Charge o Premises /1rsfo1L.. v\e'iff
z
(please print)
Signature41L Title Ce rhA rtlt' ,
(over)
DOH-1555 (02/2004)