Moore, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH , lib
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie Moore Female
Date of Death Age If Veteran of U.S.Armed Forces,
j,. February 12, 2016 82 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Fort Edward Street Address Fort Hudson Residential Health Care,
G Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Philip J. Gara, Jr. Dr.
Q Address
327 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Number 5.755 Register Ter
City,Town or Village Fort Edward
❑Burial February 2016 Pineview Crematorium
❑Entombment Address
m 0 Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
l" Hold
a
0 Date Point of
0 ❑Transportation Shipment
L by Common Destination
Carrier
Date Cemetery Address
0 ❑ Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
1-
Name of Funeral Firm Making Disposition or to Whom
$
fY Remains are Shipped, If Other than Above
W Address
a.
Permission is he eby granted to dispose of the human re ' s describe above as indicated.
Date Issued I Registrar of Vital Statistics
signature)
District Number 5 1;,) Place Fort Edward,New York
I certify that the remains of the •- •ent identified above were disposed of in accordance with this permit on:
I-
2
• i
W Date of Disposition 02/ •/2016 Place of Disposition Pineview Crematorium
W "2.-20--/fr (address)
0
0 (section) % (lot number) (grave number)
0
Name of Sexton o r 'n arge of Premises L.,/,4>n ,yn A Q
W (please print)
Signature Title G/'cyr/edp"
- (over)
DOH-1555 (0 /2004)