Moffitt, Donald NEW YORK STATE DEPARTMENT OF HEALTH ,* # 'Si.
Vital Records Section Burial - Transit Permit
=y Name First Middle Last Sex
;. Donald Ralph Moffitt Male
;= Date of Death Age If Veteran of U.S. Armed Forces,
s May 24,2015 64 War or Dates
_ Place of Death
Hospital, Institution or
-?° City, Town or Village Warrensburg Street Address 85 Hudson St.
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Lkir Circumstances Investigation
Medical Certifier Name Title
a= William Orluk
Address
l Chester Health Center,Chestertown,NY 12817
Death Certificate Filed District Number Regis er Number
City, Town or Village 5660
El Burial Date Cemetery or Crematory
CI Entombment May 27,2015 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
1 Hold
N'
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s Permit Issued to Registration Number
.' Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
v' 3809 Main Street,Warrensburg,NY 12885
., Name of Funeral Firm Making Disposition or to Whom
=u Remains are Shipped, If Other than Above
Address
CZ:
£ Permission is her by gr nted to dispose of the hums ins scribed above as indicated.
> r
Date Issued 5 /5 Registrar of Vital Statis - (i vu�z,------'
(signature)
District Number 5660 Place ��t /2
I
I certify that the remains of the decedent identified above ni re disposed of in accordance with this permit on:
Z
LU Date of Disposition S f z$jl7 Place of Disposition ,P1/,J ram,,.,,
W (address)
Cl)
QX (section) A (lot number (grave number)
Name of Sexton or Person in Charge of Premises h,� � ..
Z (please print)
w Signature A — Title f1Irolttp+t
(over)
DOH-1555 (02/2004)