Morehouse, William NEW YORK STATE DEPARTMENT OF HEALTH: 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Rigny Morehouse Male
:x Date of Death Age If Veteran of U.S. Armed Forces,
November 8,2012 77 War or Dates
" Place of Death Hospital, Institution or
City, Town or Village Bolton Street Address 9 Federal Hill Road
a, Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
: Circumstances Investigation
ILI Medical Certifier Name Title
Bryan Smead
Address
:.:Bolton Health Center,Bolton Landing,NY 12814
a ; Death Certificate Filed District Number Register Nber
: City, Town or Village Bolton 5650 iLf
❑Burial Date Cemetery or Crematory
November 9,2012 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,'1- Permit Issued to Registration Number
's 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
) Remains are Shipped, If Other than Above
Address
xR Permission is hereby granted to dispose of the human remains escribed abo as i.: Date Issued /�- �O12Registrar of Vital Statistics ���-- ,a indicat
g� �
9 L�
(signature)
,.: District Number 5650 Place Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
La Date of Disposition 11/131 iZ Place of Disposition -P,,,IUuw CrGwR,f drrt -
(address)
W
co
Ce (section) /f (lot number)(-4 (grave number)
pName of Sexton or Person in Charge of Premises r�stc JIhH -
Z I (please print)
tuifk, ..../
Signature L Title CQ,@h1 91-6
(over)
DOH-1555 (02/2004)