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Ross, Thomas Joseph .,. f . NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas Joseph Ross Male Date of Death Age If Veteran of U.S.Armed Forces, 07/26/2021 72 Years War or Dates 1966-1967 .. Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause Accident �Homicide D Suicide ❑Undetermined Pending W Circumstances Investigation 0 Medical Certifier Name Title Christopher Smith MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 313 ElBurial Date Cemetery,Crematory or Facility Name 07/28/2021 Pine View Crematorium El Entombment Address lCremation Queensbury Town,New York ❑Donation 6 ❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 O. Date Point of Cl) Li Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/28/2021 Registrar of Vital Statistics Rp6ertAndrew Curtis(ECectronicaffy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition '-' —;4 Place of Disposition p;ht, 0.4,4) cirtm,l` y 2 (address) W cr N (section) (lot number) (grave number) cName of Sexton or Person in Charge of Premises 7-t p+L P bA('C S Tplease print) w Signature jre7--' 4� Title Gr�m99.0 r DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 3 1 4 9 3 7 ' J Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#