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Moore, Lorraine J
1433 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lorraine J Moore Female Date of Death Age If Veteran of U.S.Armed Forces, 08/02/2021 84 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Indian Lake Town Street Address 106 Crow Hill Road, Indian Lake Town, New York 12842 111 p Manner of Death ©Natural Cause ❑Accident ID Homicide ❑Suicide Undetermined Pending UJ C.) Circumstances Investigation LU Medical Certifier Name Title CI Ryan Donnelly DO Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Indian Lake 2053 8 ▪Burial Date Cemetery,Crematory or Facility Name 08/03/2021 Pine View Crematory El Entombment Address lCremation Queensbury Town,New York ▪Donation O ElRemoval Date Place Removed and/or and/or Held h- Hold Address (1) 0 a Date Point of U) ❑Transportation Ca Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/03/2021 Registrar of Vital Statistics Julie A Clawson(Electronically Signed) (signature) District Number 2053 Place Indian Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l- W Date of Disposition /�aos.l Place of Disposition p jn j, ft cm, (�Cc' qc.v 2 (address) W N CC (section) (lot number) (grave number) O Name of Sexton or Person in Charge of Premises �YJJ�r e S Z / (please print) tL ��Signature /nrh!�! h,., Title CrL•vrdt,(' DOH-1555(07/18)p t of 2 I c et 015000 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#