Mosher Sr., martin C ' 33�
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Martin C Mosher Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/08/2021 85 Years War or Dates Army
E., Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
ILI
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
W Circumstances Investigation
U
Q Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 12
▪Burial Date Cemetery,Crematory or Facility Name
04/09/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
O Donation
ZO Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
U) ❑Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f. Remains are Shipped,If Other than Above
2 Address
W
O' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2021 Registrar of Vital Statistics Kflaken C Loran gkctronicallySigned
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition S�/G1- jy / Place of Disposition ]/e it el-..Z,t c
2 (addresst—
III
CC (section) (io number) (grave number)
Name of Sexton or Person in Charge Premises / ��l�llf✓ L (please print)
W l
Z
Signature �"'� Title
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 0 I 47 0 7
Receipt
Human remains of delivered on , 20;
Pine View Cemetery Representing the funeral hom6 named on burial permit
Official Funeral Directors Reg.or License#