Moore, Andrew .,t 3J
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;:;fr Name First Middle Last Sex
L r; Andrew W. Moore Male
0 r, Date of Death Age If Veteran of U.S. Armed Forces,
c.v.. April 22, 2016 72 War or Dates
r' '
1 Place of Death Hospital, Institution or
City, Town or Village Milton Street Address Gateway House
Manner of Death XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.; John Stoutenburg MD
ii:J Address
,.;f 102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number r Register Number
s ; City, Town or Village Town of Milton �"56 I ci�
❑Burial Date Cemetery or Crematory
April 25, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
1-7 Reinterment Date Cemetery Address
r Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
„_, Address
:{ 53 Quaker Road, Queensbury,NY 12804
:ej; Name of Funeral Firm Making Disposition or to Whom
I"�. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ins describe. • ve as indicate
;r:
:;r;;, Date Issued y'2.n/►L? Registrar of Vital Statisti 0 A ✓ )
:N:
(signature)
District Number `\-5b i Place 7oLtokeTh 0-t Mt►t
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition t(/17M/(, Place of Disposition 'Pa IL C Qtori..
W (address)
CO
CL
0 (section) /� (lot number) ^ (grave number)
pName of Sexton or Person in Charg of Premises l�arj}rl, J,
Z (pl ase print)
Signature
L_ Title r }
(over)
DOH-1555(02/2004)