Moeller, Caroline NEW YORK STATE DEPARTMENT OF HEALTH 4 'iIic
Vital Records Section ` .4 Burial - Transit Permit
nName First Middle Last Sex
Caroline L. Moeller Female
Date of Death Age If Veteran of U.S. Armed Forces,
A June 17,2015 96 War or Dates n/a
'''' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 8 Horicon Ave
Manner of Death C Natural Cause ❑Accident 0 Homicide E Suicide E Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Reeves,MD
f' Address
r:h,F"l Glens Falls,NY
kr
Death yTown or Vi
llage g Glens Falls,NY Filede District Number RegisterRegi .3r Number
6 er
❑Burial Date Cemetery or Crematory
June 19,2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
ZZ C Removal and/or Held
and/or Address
I' Hold
a.
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
O
Reinterment Date Cemetery Address
ri`
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury, NY 12804
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
;=,r/ Permission is hereby granted to dispose of the human�fle rains describe above as i icat dam. p
Date Issued / Registrar of Vital tatistics e�
r "
' %l signs ure
District Number J3"��, / Place �� n�, (
I certify that the remains of the decedent identified above were disposed of irfaccordance ith this permit on:
Z
WW Date of Disposition (o X- i5 Place of Disposition ,'n e u,e w Ccevlick-k of i vavv1
(address)
W
CO
Oeite.glipn)F (lot number) (grave number)
p Name of Sexton or Person in Charg of Premises t trv►0'FN un{lie
W \
Signature Title C/'eri‘4,vey yq-Sd
(over)
DOH-1555(02/2004)