Moore, James NEW YORK STATE DEPARTMENT OF HEALTH
� / C
Ne
Vital Records Section Burial - Transit Permit
.. Name First Middle Last Sex
James A. Moore Male
. Date of Death Age If Veteran of U.S. Armed Forces,
November 4, 2013 Y/ War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑ Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
� Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number ` Regis.!Number
City, Town or Village Glens Falls r)t 1
113
❑Burial Date Cemetery or Crematory
November 12, 2013 Pine View Crematory
❑Entombment Address
,ti,, ®Cremation Quaker Road Queensbury,NY 12804
Removal Date Place Removed
and/or and/or Held
Hold Address
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'; Permit Issued to
Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains describ dd above s in d.
Date Issued //J7�2OL3 Registrar of Vital Statistics /� ,' "/_-r
(signature)
"w District Number .,5 / Place 67 ls NY
I certify that the remains of the decedent identified above were disposed of in accorOace with this permit on:K
Date of Disposition 11/12/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Iii
(section) t num r)
6 (grave number)
Name of Sexton or P s• in e of Premises dv✓ d
(pl ase print
Signatu/ ��1/ Title 0/D� -t.
(over)
DOH-1555 (02/2004)