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Moss, Ronald NEW YORK STATE DEPARTMENT OF HEALTH t 7°3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ronald James Moss Male Date of Death Age If Veteran of U.S. Armed Forces, September 27, 2016 82 War or Dates ▪ Place of Death Hospital,Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of DeathE.i Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title CI Marvin Davidowitz, M.D Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number v .J\ Register Number City, Town or Village ❑Burial Date Cemetery or Crematory September 28, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held ▪ and/or Address Hold CO Date Point of O ❑Transportation Shipment __ 0) by Common Destination CI Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above M Address IX CL Permission is hereby granted to dispose of the human re ains de ribed above as indicated. Date Issued__Cc Registrar of Vital Statistics Aril _ /4' . _ 2 (signature) District Number �o 1 Place C &-1 11'4 H I certify that the remains of the decedent identified above were d' posed of in accordant ith this permit on://��,, W Date of Disposition 09 2016 Place of Disposition Quaker Road Queensbury,NY 12804 : �tet),Gu/'"('m .,' (address) W' ce (section) k (lot n mber) (grave number) dName of Sexton o o in Charge of Premises !�,)l4 6d- e,..di. z, (please print) W` Signature Title �� � � (over) DOH-1555 (02/2004)