Moore, June WOW
It
NEW YORK STATE DEPARTMENT OF HEALTH 31
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June Lorraine Moore Female
Date of Death Age If Veteran of U.S. Armed Forces,
-> January 12,2014 80 War or Dates
r#.y Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
ttl` Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
13' Circumstances Investigation
ut Medical Certifier Name Title
a Dr.William Borgos
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number RegiApr Number
City, Town or Village Glens Falls 5601 0
ā¯‘Burial Date Cemetery or Crematory
II
Entombment January 14,2014 Pine View Crematory
Address
®Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
t' Hold
U)
0 Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
1 Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1° Remains are Shipped, If Other than Above
Address
ce
0`, Permission is h re y granted to dispose of the human rnains de ribed ab ve as indica d.
Date Issued 0 / Q/ Registrar of Vital Statistics U ' , &P ,
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were d posed of in accordance with this permit on:
w Date of Disposition j As-IN Place of Disposition Zeki iw 6,vitor16E
W (address)
cn
(section) (l t number) (grave number)
QName of Sexton or Person in Charge of Premises /1I 6 1,r ..4--
Z 4L.,
(J,lease print)
wSignature i Title 4/ t
(over)
DOH-1555 (02/2004)