Moore, Jessica NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jessica Mane Moore Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/30/2014 28 years War or Dates
• Place of Death Hospital, Institution or
1.1 City, Tows CA XX Glens Falls Street Address Glens Falls Hnspital
• Manner of Death❑Natural Cause 0 Accident 0 Homicide D Suicide 0 Undetermined Effending la Circumstances 'investigation
la Medical Certifier Name Title
CI
Paul Bachman Cnrnner
Address
Warrensburg Health Center, Warensburg, NY
Death Certificate Filed District Number ,Register Number
City, Towin j(illki9 xx Glens Falls 5601 56
❑Byrial Date Cemetery or Crematory
❑Entombment 02/06/2014 Pine View Cemetery
Address
❑Cremation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
a Hnd/ldor Address
to o
O Date Point of
Q` Trans ortation
❑ P Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home, Inc. 1425
Address
136 Warren Street~ Glens Falls, NY
Name of Funeral Firm Making Disposition or to Whom
iF= Remains are Shipped, If Other than Above
a Address
a
ILI
it
Permission is hereby granted to dispose of the human remains describe above a indi
Date Issued 02/03/2014 Registrar of Vital Statistics Lf r
(signature)
District Number Place
5601 Glens Falls
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
3/31 /14 p
ill Date of Disposition Place of Disposition Pine View Cemetery
till
(address)
ilk Horicon 28 B 1
1e (section) (lot number) (grave number)
Name of Se on or Person in Charge of Pre . es Connie L. Goedert
(please print) •
Si nature i Superintendent
Title
(over)
DOH-1555 (02/2004)