Moses Sr, Clifford NEW YORK STATE DEPARTMENT OF HEALTH ` It to
Vital Records Section Burial - Transit Per it
ig Name First Middle Last Sex
iigi "l forte fLmfolED A. Moses Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
9/1 /201 6 95 War or Dates WWII
.1 Place of Death Hospital, Institution or Lake Luzerne
City, Town or Village Lake Luzerne Street Address 1 760 Glens Falls Mtn. Rd
q Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
ILI Circumstances Investigation
iti Medical Certifier Name Title
O. George Siniaphn MD
Address
604 Palmer Avnue, Corinth, NY
: Death Certificate Filed District Number Register Nyjnber
City, Town or Village Lake Luzerne v
ffi❑Burial Date Cemetery or Crematory
❑Entombment 9/2/16 Pine View Crematory
ffi Address
®Cremation Quaker Road, Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
�= Hold
0
a Date Point of
M El t
Transportation Shipment
L5 by Common Destination
61 Carrier
Disinterment Date Cemetery Address
ni
❑Reinterment Date Cemetery Address
:' Permit Issued to Registration Number
, Name of Funeral Home Densmore Funeral Home co L{L,� 27
:
Address
7 Sherman Avenue, Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
I
lI
Permission is hereby granted to dispose of the human remains describ- , a•ova, as indicated. Q
'.: Date Issued 9'- a-j� Registrar of Vital Statistics ��'� /C�r X-4 a� .
�V/ /J ","` . (signature)
District Number Plac ' A
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k l� Date of Disposition 9IZ(16 Place of Disposition l�Vf)
6r 1v;+--
x (address)
tii
0)
(section) ,.(lot number?- (grave number)
E. Name of Sexton or Person in Charge of Premises dirrts-, JcN01
2 Aase print)
• Signature Title117,k4077-14
(over)
DOH-1555 (02/2004)