Mosher, Levi C. 01 2a/202d 2 2 1 j 6 t 2'1@77 NORTHV iLLE PJNEEERRAL PAGE 0
V"f *�► Burial • Transit Permit
UM Mi
AP 1-ir of U WOW
1 f 1,12 20 87 War or Was NA
T4 City of Gloversville Stn*Addraft Nathan Littauer Hospital
Undetermined Ming
010umet8rtces IIVNVtion
Margaret Lack - Coroner
Address
223 W Main Street. Johnstown NY _
Res ter Number'
ay,T ntown� City of Gloversville � 1701 — � 21
dw Dole 1 2,1l2020 i tP ne 1�1�w Crematory
Queensbuna, New York
;:. t5 S�t ue Rid
Rereo+ral andhw Held -----
wow l4a48r s
ti�{Wd
tote �Paint
by Crrutn
Canie' -- ----
[D Disintemnsrst
t _ CemeteryAddrew
f;y
Rwr;tsment ..»
ipra Number
err1 !fSSu tiitiCiI'
Narne of Fury W i•°onw Alexander- Faker Funeral Horne C037
l .r
3809 Main
time of Funeral Pirm Makog Dispasftian or to Whom
Ftemai are$rp :,If q"r than Awe
Addaws
PenWsslon is hereby grantied to dispose of the human i ne dess7ork
b furled.
Date issued 1 r21 f2020 Rovistrar of 1�U Statistics
f rict Nufte 1701 p1m City of Glov r- ills, New
I cw#y filet(no remains of Its decedent idar►Ntied above were disposed of in ac.ordar►ce wtt,this po mit on:
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Date of f.NaOtasitian�J.LLLLZp Place ot C?isptss4do^
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M•s +d + mx1- (slaws reu*W)
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Natm sit Saxton or Person in "hargr of Pt 4" 1AIL
Q
Title
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€�QH-1,�5 rw42C2GG�
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3264
Public Health Law Sec. 4145(2b) 01
Receipt
d .
Human remains of ;' ` delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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