Moss, George H y . # III
NEW YORK STATE DEPARTMENT OF HEALTH Burial-Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George H.Moss Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/03/2022 61 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 32 Feeder Street,Hudson Falls Village,New York 12839
pManner of Death EINatural CauseAccident 0 Homicide Suicide ❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Mark Quaresima MD
Address
9 Carey Road,Oueensbury Town,New York 12804
Death Certificate Filed Vilage Of Hudson Fails District Number Register Number
Cit.,Town or Ville 5726 12
Burial Date Cemetery,Crematory or Facility Name
03/04/2022 Pine View Crematorium
Entombment Address
Cremation Oueensbury Town,New York
Donation
An Removal Date Place Removed
and/or
N and/or Held
E= Hold Address
—
Date Point of
W Transportation Shipment
by Common
Carrier Destination
DDisinterment Date Cemetery Address
isinterment
IDReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
11— Remains are Shipped,If Other than Above
X Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics CyntkaA 4r4in(Ele t Si&nad)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i.—
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'
WDate of Disposition ,j 219J� V 'Place of Disposition ,Je i/et,f) C , v_ fi�
2 (address
W
NlE (section) (lot nu berg i (gave number/
2 ,n foe Name of Sexton or Person in Charge f Premises la��®^ print/
Z 1
in Signature 7i1 / Title D
DOH 1555(07/18)p 1of 2
,� v 1I -J(.)
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#