Vrooman, Ross Michael NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ross Michael Vrooman Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/03/2022 72 Years War or Dates 1969-1974
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p• Manner of Death El Natural Cause EAccident Homicide Suicide ❑Undetermined ElPending
C.) Circumstances Investigation
WQ Medical Certifier Name Title
Jean Flanagan MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 144
Burial Date Cemetery,Crematory or Facility Name
03/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
nDonation
n�Removal Date Place Removed
g and/or and/or Held
N Hold Address
O ..,.,
L- gate Point of
U) Transportation
p by Common Shipment
Carrier . Destination
ElDisintermeri
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
U— Remains are Shipped,If Other than Above
2 Address
CC
W _ _
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2022 Registrar of Vital Statistics Megan Norn(Ekctfortc ,f'i*Jned)
(signature)
District Number 56Q1 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 3111 7Z. Place of Disposition /!_ Alf
W
2 (address)
W
N (section) /lot number) (grave number)
CC �
Name of Sexton or Person in Charge of Premises 4-�\� ✓,,,Ait
Z (pleas riot)
W Signature Title r` m��iXt
DOH 1555(07/18)p 1 of 2
t:� Elf-
, Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#