Moore, Dorothy Elizabeth NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothy Elizabeth Moore Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2024 91 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death El Natural Cause Accident El Homicide ESuicide ElUndetermined Pending
W
U Circumstances Investigation
aILI Medical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 119
XBurial Date Cemetery,Crematory or Facility Name
03/02/2024 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
W❑Transportation
a by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H 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 02/28/2024 Registrar of Vital Statistics Megan Nolin(ECectronicallySigned)
(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:
I-
W Date of Disposition '3.Q.a t.\ Place of Disposition DUC.kiCR S S 0 l ..n ui.-...1 l Q80 U
5 (address)
W \\C,a;c(NM 4 C.
Cl)CC (sect/ (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises —tom. Z.T
Z (please print
W Signature /�"��'�''�`� -� Title7e ► n �
DOH-1555(07/18)p 1 of 2
5` 1
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
MOORE Lot No. 42 C
Address 27 Twicwood Lane, Queensbury, Ny 12804 LF Section No.
Owner Dorothy Moore Plot Horicon
Date 6/17/2014
Approx. 133 Superficial ft.
Location Bounded on the North by Vacant, East by Vacant
West by Road and South by Vacant
Corner Posts
Remarks 518-798-3844
Deed No. (and changes) 3855
Payment Record paid in full on 6/17/2014 ($1 , 800.00 )
Record of Interments
20AD
2 Stewart F. Moore ( 6/26/2014) •
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Form No. 01
MOORE
NAME Dorothy Elizabeth L'' lii e Age: 91
Lot Owner: Dorothy Moore
Lot# Horicon 42 C Grave# 3
Case: Concrete
Died:2,2 7,2 4 Interred: 3.2.2 4
Funeral Home: Baker FH
Cemetery: Pine View