Moreau, Ian ftb7
NEW YORK STATE DEPARTMENT OF HEALTH ! Burial - Transit Permit
Vital Records Section
' Name First Middle Last Sex
Ian Scott Moreau Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2015 22 War or Dates
Place of Death Hospital, Institution or
w.
City, Town or Village Street Address Clark Road
WManner of Death❑ Natural Cause El Accident El Homicide El Suicide ❑ Undetermined ❑ Pending
C Circumstances Investigation
Ul Medical Certifier Name Title
a Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
'- Death Certificate Filed District,Numb Reger Number
City, Town or Village / go a
s❑Burial Date Cemetery or Crematory
January 28, 2015 Pine View Crematorium
_❑Entombment Address
'-g1Cremation Quaker Road Queensbury,NY 12804
Date 1 Place Removed
z 0 Removal I and/or Held
and/or Address
Hold
f Date Point of
a-❑
p. Transportation Shipment
by Common Destination
14, Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
3= Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
1:14, Permission is hereby granted to dispose of the humanEmains descri -d •ove as indicated.
Date Issued 11.714/4 i/ - Registrar of Vital Statistics I!( 1 II%
_� M District Number � /)
Place (Jy.) O t✓//l1i gg 4d , / 4,41mi.a blg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
W Date of Disposition 01/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
11w''
to
i (section) /l (lot number (grave number)
0 Name of Sexton or Perso in Char a of Premises ". �""
(please print)
. Signature Title `I7 "'fgit
(over)
DOH-1555 (02/2004)