Moorman, Patricia NEW YORK STATE DEPARTMENT OF HEALTH # 5-i9
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
Patricia Ann Moorman Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 10, 2014 72 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 24 Main Street
WManner of Death J Natural Cause ❑ Accident ❑Homicide ❑ Suicide n Undetermined ❑ Pending
c„) Circumstances Investigation
WW Medical Certifier Name Title
Robert Beaty MD,
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed II/I District Number Register Number
�. City, Town rVillage F .d.,c fa I/ 7 J'6 /S
❑Burial ate Cemetery or Crematory
September 12, 2014
❑Entombment Address
®Cremation
Date Place Removed
z;❑ Removal and/or Held
a and/or Address
a= Hold
0' Date Point of
eL ❑ Transportation Shipment
0) by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
III 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
Address
IX.'
W;
a"" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued S- /I-)0/y Registrar of Vital Statistics (i - 6 '`
(signature)
District Number Ss-2 a_6, Place U;1 1 yt Q-I fici-4,4 F f/S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
w Date of Disposition 09/12/2014 Place of Disposition rat4,(A) r r.., r .
(address)
W:;',
CO
Ce (section) jf (lot number) (grave number)
0, Name of Sexton or Person in Charge of Premises an+s Jpi"`.tii
/� (please print)
Signature G�ry Title `Iil Mil
(over)
DOH-1555 (02/2004)