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Mosher, Howard NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Howard William Mosher Male } Date of Death Age If Veteran of U.S. Armed Forces, 10/02/2018 86 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause Ej Accident Homicide Suicide El Undetermined ri Pending Circumstances Investigation Medical Certifier Name Title Marcille Labban MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 471 Date Cemeteryor Crematory ®Burial 10/05/2018 West Glens Falls Cemetery ❑Entombment Address ••- "e _-Queensbury-Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier T Q Disinterment Date Cemetery Address Date Cemetery Address Renterment • 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 Remains are Shipped, If Other than Above rw Address • Permission is hereby granted to dispose of the human remains described above as indicated. • Date Tssued- 10/03/2018 Registrar of Vital Statistics /(96ertA Curtis gCectmnically 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: Date of Disposition 1 0/5/201 place of Disposition WEst Glens Falls Cemetery (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises Connie Goedert (please print) • Signature: Title Cemetery Superintendent (over) DOH-1555(02/2004)