Moore, Carroll NEW YORK STATE DEPARTMENT OF HEALTH # q°1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carroll Ruth Moore Female
7 Date of Death Age If Veteran of U.S. Armed Forces,
May 30, 2016 73 War or Dates
Place of Death Hospital, Institution or
uji City, Town or Village Glens Falls Street Address 3E Stitchman Towers
0 Manner of Death❑Natural Cause El Accident El Homicide El Suicide ❑ Undetermined ri❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number � O( Register Number a�,�
bc2 t
, - City, Town or Village
0 Burial Date Cemetery or Crematory
June 2, 2016 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
0 and/or Address
r Hold
6 Date Point of
Transportation Shipment
1 by Common Destination
d Carrier
ElDisinterment Date Cemetery Address
...........
Date Cemetery Address
El 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
2 Address
CC
Wa.
q Permission is hereby granted to dispose of the human r main escribe above a ndi =ted.
Date Issued O G, c z zp(a Registrar of Vital Statistics , 4/,(p�-, a 42
,(signature)
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District Number �(00 / Place - Gz—� /7 t'
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
w Date of Disposition 06/02/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
CO
re (section) (lot number) (grave number)
p'' Name of Sexton or Person in Charge of Premises ^`` L
Z (lease print)
W� Signature7) Title c '
(over)
DOH-1555 (02/2004)