Moynihan, James VC
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Jay Moynihan Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 25,2017 66 War or Dates n/a
1... Place of Death Hospital, Institution or
2 City, Town or Village Queensbury,NY Street Address 653 Bay Road
W:' Manner of DeathUndetermined Pending
� n Natural Cause n Accident E Homicide �Suicide n C
W Circumstances Investigation
w Medical Certifier Name Title
Shannon Evellis,Dt
Address
Chestertown,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY _ 5657 l 50
❑Burial Date Cemetery or Crematory
El Entombment November 29,2017 Pine View Crematory
Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
ZZ n Removal and/or Held
2 and/or Address
H Hold
CO
O Date Point of
NU Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home Regan Denny Stafford 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1-, Remains are Shipped, If Other than Above
a Address
W
W
"' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t t -a.F-ZD ti Registrar of Vital Statistics - QQA-L- --tic. . Qom.
(signature)
District Number S()5 1 Place (.)0 tc_/t s hvv
I certify that the remains of the decedent identified above were-disposed of in accordance with this permit on:
wDate of Disposition j2/i /0Place of Disposition ?mow 4 or:..�
W (address)
Cl)
W (section) p (lot number) (grave number)
pName of Sexton or Person in Charge of Premises r‘, S.."-..ter
Z n lease print)
w Signature 4
Ae.4Title Ckrol
(over)
DOH-1555(02/2004)