Moore, Robert A," ..-, Pr 7b e
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert J Moore Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/24/2015 79 War or Dates 1950-1955
(-. Place of Death Hospital, Institution
Z: City,Town or Village City of Albany or Street Address Albany Medical Center
G. Manner of Death Natural ❑ Undetermined ❑ Pending
tll ® Cause ❑ ID Accident Homicide Suicide Circumstances Investigation
W Medical Certifier Name Title
1 Tarek Dakakni MD
Address
43 New Scotland Ave Albany, NY
Death Certificate Filed District Number Register Number
f' City,Town or Village City of Albany 101 2015
Date Cemetery or Crematory
❑ Burial 09/28/2015 Pine View Crematorium
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
2 ❑ and/or Address
F-' Hold
U
0 Date Point of
tL Transportation Shipment
tn, 0 By Common Destination
CI Carrier
❑ Date Cemetery Address
Disinterment
El Reinterment
Cemetery Address
Reinterment
y Permit Issued To Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
La'
0. Permission is hereby granted to dispose of the human remains desc 'bed above as indicat .
Date 09/25/2015 �, ,e /C Issued Registrar of Vital Statistics
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
Z'' Date of Disposition ' j3011'� Place of Disposition t'IA , Ci ct&tt'-
Ui' (address)
iJJ':I
U)
� (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Stn
ILI
(please print)
Signature G'Cr Title f
OlinetrA
(over)
DOH-1555 (02/2004)