Moon, Jr. Rexford NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
ii Name First Middle Last Sex
Rexford G. Moon Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/30/2011 89 years War or Dates Wwii
}; Place of Death Hospital, Institution or
City, To Street Address
} �✓ (X Sohanantady Ellis Hospital
Manner of Death❑1atural Cause 0 Accident ED Homicide 0 Suicide ElUndetermined ri Pending
Circumstances Investigation
tu Medical Certifier Name Title
r4 Piotr.Iaworowski M D
Address
Ellis Hospital, 1101 Nott St, Schenectady, N Y
Nsi Death Certificate Filed District Number Register Number
City, TovkViX Schenectady 4601 667
00Burial Date Cemetery or Crematory
Entombment 08/01/2011 Pineview Crematory
Address
❑cremation Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
I= Hold
Date Point of
tan Li Transportation Shipment
.: by Common Destination
in Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00440
iii Address
7 Sherman Ave., Corinth, N.Y.
Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
Address .
Ilia
X It Permission is hereby granted to dispose of the human remains •;s 4, .- ; bb �ip d,
—fi r 1
Date Issued 08/01/2011 Registrar of Vital Statistics
(signature)
iN
`' District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition K-Z-li Place of Disposition R• Ltw �'rrti,ta c.ri10•.,
(address)
Ili
C
CC (section) /1 (ioynumber) (grave number)
CI Name of Sexton or Pe on in Ch rge of Premises ` h( r :vu (k
_ (please print)
:: •Si nature Title C� EM TD4(
9 kl
(over)
DOH-1555 (02/2004)