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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wesley Robert Mosher Male
Date of Death Age ' If Veteran of U.S.Armed Forces,
March 24,2014 72 War or Dates
l . Place of Death Hospital, InstitutiorBillton Center For Rehabilitation And
Z City,Town or Village Town of Johnstown Street Address Aeslthrarr
O Manner of Death d Natural Cause Accident Q Homicide El Suicide �Undetermined n Pending
la Circumstances Investigation
in Medical Certifier Name Title
0 Jonathan Celina NP
Address
847 County Highway 122,Gloversritle NY 12078
Death Certificate Filed District Number ! Register Numlle7
City,Town or Village Town of Johnstown 1754
❑Burial Date Cemetery or Crematory
0Entombmeit March 26,2014 _ Pine View Crematory
Address
i2C)Cremation Queensbnry,NY
Date 1 Place Removed
Z 71 Removal and/or Held
Q andlor Address
t: Hold
O� Date Point of
Si 0 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D.Baker Funeral Home 01130
Address
11 Lafayette Street,Queensbury,NY 12804 —
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
'2 Address
cr
'ut
o. Permission is hereby granted to dispose of the human remains dei ed above 7/indicated.y
Date Issued .,A20) Registrar of Vital Statistics
�
�t
signature)
District Number 1754 Place Town of Johnstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition 31a-1 I i Place of Disposition itxtOi+ra Ire of, ..
(address)
W
co
fY (section) (tot ( numberName of Sexton or Person in arge of Premises Jnumber) Sie
Z ( se Print
LU Signature Title Clt(Wilttlej
(over)
DOH-1555(02/2004) .
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wesley Robert Mosher Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 24,2014 72 War or Dates
f,., Place of Death Hospital, Institutior1lton Center For Rehabilitation And
Z City, Town or Village Town of Johnstown Street Address Healthcare
iii
ct Manner of Death `X)Natural Cause 1 lAccident —}Homicide ` Suicide Undetermined Pending
tu Circumstances Investigation
W Medical Certifier Name Title
0 Jonathan Colino NP
Address
847 County Highway 122,Gloversville,NY 12078
Death Certificate Filed District Number Register Numr)
City, Town or Village Town of Johnstown 1754
❑Burial Date Cemetery or Crematory
Entombment March 26,2014 Pine View Crematory
— Address
EICremation Queensbury,NY
Date Place Removed
Z f j Removal and/or Held
0 and/or Address
E Hold
0 Date Point of
a.
Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i-, Remains are Shipped, If Other than Above
3 Address
re
a.' Permission is hereby granted to dispose of the human remains d�ed above a�jnd_ ic�.
,. X5 Date Issued 67 Registrar of Vital Statistics /�lve�(
signature)
District Number 1754 Place Town of Johnstown
-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ili Date of Disposition Place of Disposition
(address)
W
CO
1Y (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises
Z (please print)
w Signature Title
(over)
DOH-1555(02/2004)