Moar, Arlene NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arlene Hilda Moar Female
Niii Date of Death Age If Veteran of U.S. Armed Forces,
03/15/2012 68 years War or Dates
Place of Death Hospital, Institution or
City, X%XXoXXXX ? Saratoga Springsill Street Address Saratoga Hospital
Manner of Death Natural Cause El Accident Ei Homicide ❑Suicide riUndetermined El Pending
l Circumstances Investigation
W Medical Certifier Name Title
44 Desmond Del Giacco M D
Address
59 Myrtle St, Saratoga Springs, Ny 12866
ig Death Certificate Filed District Number Register Number
in City, 71X00CoMingt Saratoga Springs 4501 126
❑Burial Date Cemetery or Crematory
03/16/2012 Pine View Crematory
i ❑Entombment Address
F]Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
❑and/or Address
H Hold
(1)
0 Date Point of
f•�
• Transportation Shipment
t
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
;iiiiiiiEl Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street, Queensbury, N Y 12IN
mi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
1` Permission is hereby granted to dispose of the human remain ib abo)JA as indicated.
g Date Issued 03/16/2012 Registrar of Vital Statistics
(signature)
Iii District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z`.<„ --�
l .Date of Disposition --Iy-. 2. Place of Disposition �,nt, u i pw Cre i...wtor,'u w
2 (address)
lit
Ca
CC (section) (lot number) (grave number)
0
ta Name of Sexton or Person in C rge of Premiseshi rvii * y n A/C
2 jel / (please print)
Signature "'"',"'"y ,f,,.a. Title CterriA.ter7 --.
(over)
DOH-1555 (02/2004)