Mosher, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firsbavid Middle Isaac LIsllosher Sex Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/23/2013 86 years War or Dates 1943-1946
Place of Death Hospital, Institution or
Gown or igreViX Town of Saratoga Street Address 163 County Road 67
Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
lid Circumstances Investigation
tu Medical Certifier Name Title
L? Edward M. Liebers M D
Adreare Lane, Suite 300, Saratoga Springs, NY12866
V. Death Certificate Filed District Number Register Number
kown or A Town of Saratoga 4565 8
['Burial Date Cemetery or Crematory
10/24/2013 Park View Crematory
['Entombment Address
ElCremation Queensbury, NY
Date Place Removed
2❑Removal and/or Held
2 and/or Address
b Hold
to
0 Date Point of
ti❑Transportation Shipment
G"t by Common Destination
Carrier
iisiQ Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave,, Saratoga Springs, NY
Name of Funeral Firm Making Disposition or to Whom
:: Remains are Shipped,If Other than Above
2 Address
LC
U
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/24/2013 Registrar of Vital Statistics qta..,./:A., 4
(signature)
District Number 4565 Place Town of Saratoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
lil Date of Disposition 10/zr113 Place of Disposition ,, AA,J (,,i,,,ct-Dr„
2 (address)
ua
to
gc (section) / (lot number) „" (grave number)
aName of Sexton or Person in C arge of Pre ises At, Jthr+lt
Z. (ple se print)
Signature Title Cerillic00
(over)
DOH-1555 (02/2004)