Moschetto, Thomas # A%
NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section s Burial - Transit Permit
.°: Name First Middle Last Sex
1Thomas Moschetto Male
.2. - Date of Death Age If Veteran of U.S. Armed Forces,
June 20, 2014 94 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 16 Owen Ave.
Manner of Death X Natural Cause [ 'Accident ri Homicide , Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Eric Pillemer MD
r Address
:R Glens Falls Hospital, 100 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
. , City, Town or Village Glens Falls 5601 18
❑Burial Date Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I 'Removal and/or Held
and/or Address
.' Hold
0 Date Point of
N' Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<1:?:1 Permit Issued to Registration Number
:;:; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
iii'i' Address
Fora 53 Quaker Road, Queensbury,NY 12804
Oi Name of Funeral Firm Making Disposition or to Whom
141 Remains are Shipped, If Other than Above
I Address
Permission is hereby granted to dispose of the human re ns d ; - ,i . - s indicated.
.g. Date Issued 1p- C�14 Registrar of Vital Statistics saki-0 , •
(signature)
:fir
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition (0 !Uhl Place of DispositionP4✓ C� i—'
(address)
W
CO
O (section) (loiumber) (grave number)
p Name of Sexton or Person "n Charge o Premises L�fr)1
Z (please int)
W yL Titles
Signature /
(over)
DOH-1555(02/2004)