Loading...
Moses, Thomas Orin NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas Orin Moses Male Date of Death Age If Veteran of U.S.Armed Forces, 01/10/2020 69 Years War or Dates 1968-1974 Place of Death Hospital,Institution or WCity,Town or Village Lake Luzerne Town Street Address Glens Falls Mountain Road,Lake Luzerne Town,New York 12846 p Manner of Death Natural Cause Accident Homicide ©Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title Connie Goedert Coroner Address "I 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 1 ❑Burial Date Cemetery,Crematory or Facility Name 01/13/2020 Pine View Crematorium Entombment Address ICremation Queensbury Town,New York ❑Donation OZ Removal Date Place Removed and/or and/or Held @ Hold Address O d Date Point of N Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address "❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/13/2020 Registrar of Vital Statistics Cynthia Sherwood(ECectronicaCCySigned) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition j�lS�io Place of Disposition 1u �fdr W (address) W N (sedion) (lot number) (grave number) cc O Name of Sexton or Person in Charge of Ppernises rt (lease prin W Signature E^Id Title ` 2 DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013212 Receipt Human remains of delivered on , 20 r i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# i I I I I I i