Loading...
Moses, Michael NEW YORK STATE DEPARTMENT OF HEALTH ;- ..-1 # 2'80 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Michael C Moses Male Date of Death Age If Veteran of U.S. Armed Forces, 04/11/2016 70 years War or Dates Vietnam }r- P of Death Hospital, Institution or 4CWTOlicalt WOW Glens Falls Street Address Glens Falls, N Y liner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined Q Pending f Circumstances Investigation tu Medical Certifier Name Title • Eric Pillemer M D Address 100 Park Street Glens Falls, Ny 12801 h Certificate Filed District Number Register Number Cit TdlubFdCXrNUM Glens Falls 5601 193 urial Date Cemetery or Crematory 04/12/2016 Gerald B Soloman Nation Cemetery ❑Entombment Address ©Cremation Schuylerville, N Y Date Place Removed Z Removal and/or Held 2 and/or Address H Hold W. Date Point of Transportation Shipment G by Common Destination Carrier M ElDisinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Edward L. Kelly Funeral Home 00519 Address Schroon Lake, N Y 12870 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address Ili Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/12/2016 Registrar of Vital Statistics I.- rA (signatur District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z f Date of Disposition V f p ni, Place of Disposition Fµ�,_. �ryn....- 2 (address) tia to cc (section) /v ,..(lot number) (grave number) Ci Name of Sexton or Person in Charge of Qremises C ` r,i- S z (please print) i Signature Title OliffriiPt, (over) DOH-1555 (02/2004)