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Mosher, George Elma . ..... L O, y Jr -ni.I NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Georgie Elma Mosher Female Date of Death Age If Veteran of U.S.Armed Forces, 03/20/2023 52 Years War or Dates F.. Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Village Street Address 3106 State Route 196 Apt.3,Fort Ann Village,New York 12827 ILI Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending U Circumstances Investigation W Medical Certifier Name Title G Aimee Mcmaster NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of Fort Ann District Number Register Number City,Town or Village 5723 2 Burial Date Cemetery,Crematory or Facility Name 03/22/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation ZZ 0Removal Date Place Removed and/or and/or Held E Hold Address U) 0 d Date Point of (!)OTransportation p by Common Shipment Carrier Destination ElDisinterment 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 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above a Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/22/2023 Registrar of Vital Statistics Barbara IWinc/ie(C(ECectronica(TySigned) (signature) District Number 5723 Place Village Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3'71f 11,3 Place of Disposition "t �.�,U4 �*or:--t_... IJJ 2 (address) W CCCC (section) g (lot number) (grave number) gName of Sexton or Person in Charge of Premises z olease print) W Signature L Title �IZr.rmq ? DOH-1555(07/18)pi of 2 0M 5 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 f�' Pine View Cemetery Representing the funeral home named on buril pftrmit Official Funeral Directors Reg.or License# '