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Ross, James 451 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Qr Burial - Transit Permit Name First Middle Last Sex James Bruce Ross Male Date of Death Age If Veteran of U.S. Armed Forces, November 7, 2012 86 War or Dates Navy 1 Place of Death Hospital, Institution or Z. City, Town or Village Queensbury Street Address Westmount Health Facility ,p Manner of Death n Natural Cause ( I Accident I (Homicide Suicide Undetermined Pending AU Circumstances Investigation u Medical Certifier Name Title Roslyn Socolof Dr. Address 42 Gurney Lane,Queensbury,NY 12804 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 N�/ ID Burial Date Cemetery or Crematory J ❑Entombment November 9,2012 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed Z ( I Removal and/or Held O and/or Address F' Hold y 0 Date Point of 55 I I Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address ReintermentI Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan& Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom k!• Remains are Shipped, If Other than Above 2, Address rt ;lilt Permission is hereby granted to dispose of the human re ins described above indicated. Date Issued //-f yQ4= Registrar of Vital Statistics jaim lid__ J ___, (signature) District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z V tar' w Date of Disposition if i olit Place of Disposition a ,.tom l ur... 2 (address) Cl)UJ (section) Afolitoit... (lot number T (grave number) Z Name of Sexton or Person in Charge of remises Je nK (please print) w n Signature Title Cur,,14 (),[., (over) DOH-1555(02/2004)