Ross, Barbara W NEW YORK STATE DEPARTMENT OF HEALTH �3
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Barbara W.Ross Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2022 87 Years War or Dates
. Place of Death Hospital,Institution or
W City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
p Manner of Death El Natural Cause Accident Homicide Suicide FlUndetermined ❑Pending
W
U Circumstances Investigation
Medical Certifier Name Title
C Michael Miles MD
Address
112 Ski Bowl Rd,Johnsburg Town, New York 12853
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 12
Burial Date Cemetery,Crematory or Facility Name
05/26/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
a Date Point of
N❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
a Address
R
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/25/2022 Registrar of Vital Statistics jean M Comstock(ECectronicaltySigned)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ( �
W Date of Disposition 512401 Place of Disposition c V` ZPrOeft _
2 (address)
W
CC (section) A (lot number) (grave number)
Name of Sexton or Person in Char of Premises 1 ! �'►&Z
/p ase print)
Zf
W Signature !C _ Title ` 'AatC
DOH-1555(07/18)p i of 2
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#