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Mosher, Roger e s 17 El NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section _ Burial - Transit Permit gl Name First Middle Last Sex Roger Edward Mosher - Male ' Date of Death Age If Veteran of U.S.Armed Forces, '. 07/12/2018 65 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Saratoga Springs Street Address Saratoga Hospital 0 Manner of Death©Natural Cause 0 Accident ❑Homicide ❑Suicide 0 Undetermined El❑Pending Circumstances Investigation la Medical Certifier Name Title i0 Bert Pyle MD ,-2 Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number wCity, Town or Village Saratoga Springs 4501 390 LJBurial Date Cemetery or Crematory :, 07/16/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York ,. Date Place Removed 2 Removal and/or Held and/or Address - Hold ek Date Point of -Q Transportation Shipment by Common Destination G� Carrier ,,,, ❑Disinterment Date Cemetery Address i_iReinterment Date Cemetery Address Pii— ''. Permit Issued to Registration Number t Name of Funeral Home Regan Denny Stafford Funeral Home 01443 W Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/13/2018 Registrar of Vital Statistics John cPEranck(ECectronicallySigned) (signature) District Number 4501 Place Saratoga Springs, New York f I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /ill li( Place of Disposition PI—.. l,,41d (address) it in X (section) g(lot number) (grave number) C�3 Name of Sexton or Person in Charge of Premises Gl 1, S r."iV7 z (phase print) In ag- Signature Title (over) DOH-1555 (02/2004)