Mosher, Ralph L s'(S
NEW YORK STATE DEPARTMENT OF HEALTH — CO Burial - Transit Permit
Bureau of Vital Records
•
Name First Middle Last Sex
Ralph L.Mosher Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/25/2022 84 Years War or Dates
ZZ Place of Death Hospital,Institution or
City,Town or Village Saratoga Springs Street Address Saratoga Hospital
LU
p Manner of Death ❑X Natural Cause Accident Ei Homicide DSuicide Undetermined ❑Pending
W
C.) Circumstances Investigation
CI
Medical Certifier Name Title
Timothy Waters DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 696
BurialEi
Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
d Date Point of
CO ElTransportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne, New York 12846
Name of Funeral Firm Making Disposition or to Whom
E.. Remains are Shipped,If Other than Above
2 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition Place of Disposition
W
2 (address)
W
N
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
Z (please print)
W Signature Title
DOH-1555(o7/18)p 1 of 2
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#