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Goss, John C
#v.% NEW YORK STATE DEPARTMENT OF HEALTH Bu rial of Vital Records - Transit Permit Name First Middle Last Sex John C Goss Male Date of Death Age If Veteran of U.S.Armed Forces, 09/28/2021 96 Years War or Dates 1943-45 f.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident El Homicide EI Suicide El Undetermined El Pending W C.) Circumstances Investigation IL)O Medical Certifier Name Title Melody Long PA Address 100 Park Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 423 ElBurial Date Cemetery,Crematory or Facility Name 10/01/2021 Pineview Crematory El Entombment Address 0 Cremation Queensbury Town,New York El Donation 6 Removal Date Place Removed and/or and/or Held E— Hold Address CO 0 O. Date Point of N ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address CC Ill a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/30/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically 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: F ) Z Date of Disposition IC!L I U Place of Disposition 7 111 2 (address) W U) l= (section) A (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premi s4' t'�' �. �•4�t Z (plea e print) W Signature Title 0 limy/ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named op huJ-ial permit Official Funeral Directors Reg.or License# "