Moffitt, Albert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Albert A.Moffitt Male
rz Date of Death Age If Veteran of U.S. Armed Forces,
a;: 08/31/2017 84 Years War or Dates
Place of Death Hospital, Institution or
4:3-F4 City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitati
Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
' Medical Certifier Name Title
Lori Killon PA
Address
170 Warren St,Glens Falls,New York 12801
D• eath Certificate Filed District Number Register Number
w C• ity, Town or Village Glens Falls 5601 467
s ❑Burial Date Cemetery or Crematory
09/06/2017 Pine View Crematory
. ❑Entombment g ® Address
Cremation Queensbury Town, New York
Date Place Removed
ri❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
per, by Common Destination
Carrier
e Date Cemetery Address
Q Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Lam_ Name of Funeral Home Alexander Baker Funeral Home 00037
.= ` A• ddress
sr 3809 Main St,Warrensburg,New York 12885
Al Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
A• ddress
•r7
tr Permission is hereby granted to dispose of the human remains described above as indicated.
v
Date Issued 09/01/2017 Registrar of Vital Statistics cgbertACurtis 'E&tronicarrySigned
z (signature)
District Number 5601 Place Glens Falls, New York
• certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q tg in Place of Disposition fit ii
,,-- C^ 6t al.....
(address)
(section) (lot number (grave number)
Name of Sexton or Person in Charge of Premises Ott pi.",vo-
(please print)
f\p /
�; Signature Title /tl
(over)
DOH-1555 (02/2004)