Moore, Clyde NEW YORK STATE DEPARTMENT OF HEALTH -4 5-
•
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clyde C. Moore Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 23,2012 64 War or Dates Vietnam
Place of Death Hospital, Institution or
Z: City, Town or Village North Creek Street Address Whitewater Manor
Ul
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Daniel Sooriabalan Dr.
Address
HHF�i,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
January 24,2012 Pine View Crematory
111 Entombment Address
®Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9. and/or Address
N Hold
Cl)
0 Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
1- Remains are Shipped, If Other than Above
'El Address
Permission is hereby granted to dispose of the human rem 'rim described a • e as indicated.
Date Issued / aqi:2-01 A Registrar of Vital Statistics WA2t.• of
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iu Date of Disposition t izT/it Place of Disposition P..r `rv►dan,.�
2 (address)
W
N
(section) (lot numbe, (grave number)
pName of Sexton or Pers n in Charge f Premises
(please print)
Signature L. Title C945 Mn4Tc1iC.
(over)
DOH-1555 (02/2004)