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Moore, Rebecca lNEW YORK STATE DEPARTMENT OF HEALTH 0 * ,! Vital Records Section Burial - Transit Permit "``` -- Name First Middle fr Last Sex Rebecca A. Moore Female y; Date of Death Age If Veteran of U.S. Armed Forces, January 4,2013 49 War or Dates il Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death n Natural Cause fl Accident 1-1Homicide n Suicide C Undetermined n Pending Circumstances Investigation_ Medical Certifier Name Title Dr.Frances Bollinger f Address r; %f Death Certificate Filed City, District Number Register Number Town or Village,�' Glens Falls 5601 ❑Burial Date Cemetery or Crematory El Entombment January 7,2013 Pine View Crematory Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z I I Removal and/or Held Q and/or Address H Hold N 0 Date Point of N0 Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address n Reinterment Date Cemetery Address Permit Issued to Registration Number :f, < Name of Funeral Home Regan Denny Stafford Funeral Home 01443 ff Address 53 Quaker Road, Queensbury, NY 12804 F,4 Name of Funeral Firm Making Disposition or to Whom r Remains are Shipped, If Other than Above Address 5; , Permission is hereby granted to dispose of the human -mains de— ribed ab€e as Indic. ed. ,,, Date Issued Registrar of Vital Statistics / /p� _ A. ,`© r (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above we .isposed of in accordance with this permit on: W Date of Disposition _26 Place of Disposition U /t , gjr✓ �J/� 1 o W (address) N CL 3 4 (1 ber)I (grave Z N (section)ame of Sexto r P rso i harge of Premises .� W j number) W (please print) n� Signature (iøvd Title C t ✓ Q �J J — c, (over) DOH-1555(02/2004)