Mosher, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
4
Name First Middle Last Sex
HELEN I. MOSHER Female
Date of Death Age If Veteran of U.S. Armed Forces,
Oct. 18, 2006 99 War or Dates n/a
Place of Death Hospital, Institution or Maplewood Manor
Z City, Town or Village Ballston Spa Street AddressBallston Ave. , Ballston Spa, N.Y.
pManner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
O Leonard Gelman M.D.
Address
20 Prospect St. , Ballston Spa. N.Y. 12020
iiiii Death Certificate Filed District Number Register Number
City, Town or Village Ballston Spa 4520 60
❑Burial Date Cemetery or Crematory
❑Entombment 10/20/06 Pineview Crematorium
Address
;:;;;Cremation Queensbury, N.Y.
Date Place Removed
Z❑Removal and/or Held
P. and/or Address
H Hold
10
0 Date Point of
ti❑Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00453
Address
7 Sherman Ave. , Corinth, N.Y. 12822
Name of Funeral Firm Making Disposition or to Whom
114 Remains are Shipped, If Other than Above
2 Address
ill
IL
Permission is hereby granted to dispose of the hu an re ains described above as' icated.
Date Issued 10/19/06 Registrar of Vital StatisticAtUip.A.A..., AO
(signs e)
District Number 4520 Place Ballston Spa, N.Y.
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lift Date of Disposition ;o i r.,/u1, Place of Disposition tint-m,.) Can.0 G�14.00-
2 (address)
Lu
CC (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises C1 r's rt tt
Fit (pleaseprint)
Signature ( ✓IM Title C Nc m cj .i
(over)
DOH-1555 (02/2004)