Mosher, Amanda Kay g (0-2.
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last • Sex
Amanda Kay Mosher Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/17/2023 65 Years War or Dates
WPlace of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death II Natural Cause EAccident El Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
E Medical Certifier Name Titles
�} Marvin Davidowitz MD
•
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Ci ,Town or
Entombment dress Village 5601 33
Burial Date Cemetery,Crematory or Facility Name
01/dress 3 Pine View Crematorium
Cremation Queensbury Town,New York
•
Donation
❑Removal Date Place Removed
and/or and/or Held
pN Hold Address
0
a. Date Point of
tAl❑Transportation
a by Common Shipment •
Carrier Destination
Disinterment Date •
Cemetery Address
Reinterment 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
-r Name of Funeral Firm Making Disposition or to Whom
. iRemains are Shipped,If Other than Above
Address
iY
ILI
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Megan Wolin(ECectronicalTySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
^___, J
Date of Disposition i h 701 l3 Place of Disposition z:i j � �
1111
2 (address)
W
CC (section) //(lot number) s, (grave number)
SName of Sexton or Person in Charge of Premises ^^'11
Z J /p/eae print/
W -02
Signature l Title � ��4
DOH-1555(07/18)p 1 of 2
Y��q
0 ti 6 U 9
Public Health Law Sec. 4145(2b) . ,y
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#