Roos, Charles Howard NEW YORK STATE DEPARTMENT OF HEALTH ` •. Burial - Transit Permit
Bureau of Vital Records _
Name First a Last Sex
Charles Howard Roos Male
Date of Death Age If Veteran of US.Armed Forces,
08/20/2021 91 Years War or tes
Place of Death dal,Institution or
Z City,Town or Village Glens Falls Street Address 16 Empire Avenue,Glens Falls, New York 12801
p Manner of Death ❑X Natural Cause Accident El Homicide Suicide ❑Undetermined Pending
W Circumstances Investigation
Q Medical Certifier Name Title
Paul Filion MD
Address
3 Irongate Center,Glens Falls,New York 12801 ,
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 356
Burial Date Cemetery,Crematory or Facility Name
08/24/2021 Pine View Crematory
0 Entombment Address
Cremation Queensbury,New York
❑Donation
6 ❑Removal Date Place Removed
and/or and/or Held
l Hold Address
0
Cl) Li Transportation Date Point of
El by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— 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 08/24/2021 Registrar of Vital Statistics RpdartJnarrewCurtrsgkctronica*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:
II—
WDate of Disposition -;2/ Place of Disposition P *e V C l )
2 address)
W
(I)
CC (section) (lot number) (grave number)
Name of Sexton or Person in Cha e of Premises ef,m,y S _,..S
Z (please print)
W Signature 42-.W Title CarFdm40
r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
1 i
Receipt
1 Human remains of ' delivered on , 20
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Pine View Cemetery Representing the funeral home nan‹,orOuria..111rmit
Official Funeral Directors Reg.or License# T _,