Moore, Edward - S ��
NEW YORK STATE DEPARTMENT OF HEALT1-1
Vital Records Section ,_ Burial - Transit Permit
Name First Middle Last Sex
Edward Vernon Moore Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/17/2017 84 War orDates Korean War
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller MD
• Address
100 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls 5 Eo I n Qtj
❑Burial Date Cemetery or Crematory
07/19/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
r• Date Cemetery Address
❑ Disinterment
❑ Date Cemetery Address
Re nterment
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan 01 821
Address
11 Algonkin St. Ticonderoga, NY 12883
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 .7 I I q j 11 Registrar of Vital Statistics wQA.�.i
(signet
District Number 5(0 ) Place 6 (ct/V‘ S \\s ' j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /24y,7 Place of Disposition Pi -1i2u Cre?,-� /r�(address)
(section) (lot number) (grave number)
Name of Sexton o rs Charge of Premises w ),4rt KC,rj?�1'.4e
(please print)
Signature Title e--/V--04
(over)
DOH-1555 (02/2004)