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Moses, Mitchell Francis NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mitchell Francis Moses Male Date of Death Age If Veteran of U.S.Armed Forces, 04/02/2020 74 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Albany Street Address Albany Medical Center Hospital 'p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending UCircumstances Investigation W Medical Certifier Name Title Christina Rudolph MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 0720 Fj Burial Date Cemetery,Crematory or Facility Name 04/03/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation � �Removal Date Place Removed and/or and/or Held ~ Hold Address t%1 O G. Date Point of N Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address FReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Edward L Kelly Funeral Home 00519 Address PO Box 548,Schroon Lake,New York 12870 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped,If Other than Above Address Ilr W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/03/2020 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition �Z6 Place of Disposition J;ZLEu-•% U (address) W (section) (lot number) (grave number) � �rc Ifi Name of Sexton or Person in Charge o Premises (pleate print/ W Signature Title DO H-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) " .113501 � Receipt a Human remains of delivered on , 20, Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# i i' i i