Moon, Thomas c IF s7ci
NEW YORK STATE DEPARTMENT OF HEALTH 59
Vital Records Section , Burial - Transit Permit
r°y Name First Middle Last Sex
Thomas J. Moon Male
a. Date of Death Age If Veteran of U.S. Armed Forces,
November 22, 2011 53 War or Dates
1.;,; Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 3856 Main St
Manner of Death X Natural Cause I Accident n Homicide Suicide Undetermined l Pending
Circumstances Investigation
t Medical Certifier Name Title
Q Nancy Carney
Address
:„,Warrensburg,NY 12885
Death Certificate Filed Distric Number Register umber
City, Town or Village Town of Warrensburg cO
❑Burial Date Cemetery or Crematory
❑Entombment Nov 23, 2011 Pine View Crematory
Address
❑Cremation Queensbury, NY
Date Place Removed
Z I I Removal and/or Held
and/or Address
E' Hold
a Date Point of
N Transportation Shipment
a by Common Destination
Carrier
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
`, 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Y
w
'' Permission is he eby granted to dispose of the human r i cribed a ve as indicated.
Date Issued // Registrar of Vital Statisti <=—Li r, L,-
(signature)
District Number 5z,6 o Place Town of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition (uno lc, ! t( Place of Disposition got VI C VIYtr
2 (address)
coLU
OG
(section) (lot number) (grave number)
ZName of Sexton or Pers n in Charg f Premises tiy'�e(>lr-v on
Li.) f (please print)
Signature /41-- Title C12on V/
(over)
DOH-1555(02/2004)