Moon, Jean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean T. Moon Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 1, 2016 90 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Queensbury Street Address 1260 West Mountain Road Apt 319
Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
ali3 Medical Certifier Name Title
Eric Pillemer, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed Dismber Register Number
City, Town or Village Queensbury
®Burial Date Cemetery or Crematory
April 30, 2016 Southside Cemetery
❑Entombment Address
0 Cremation Route 32 Town of Moreau South Glens Falls,NY 12803
Date Place Removed
1'ni Removal and/or Held
and/or Address
t; Hold
N' Date Point of
� ❑Transportation Shipment
07 by Common Destination
0 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
iX
n' Permission is h eby //ranted to dispose of the human r= . s described abov as in cated.
Date Issued/� /Z.D Registrar of Vital Statistic j _p__,
_ (signature)
District Numbers 73 Place .1 47 2 ..cv,e.„..)-.,/ew
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iiDisposition p 04/30/2016 Place of Disposition Route 32 Town of Moreau South Glens Falls,NY 12803
2 Date of
(address)
MI
14 (section)
(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises
(please print)
U' Signature Title
(over)
DOH-1555(02/2004)