Moon, Katherine a ,., if I6
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
„
Name First Middle Last Sex
?`'. Katherine M. Moon Female
'f4'''4 Date of Death Age If Veteran of U.S. Armed Forces,
gt February 10, 2013 67 War or Dates
Place of Death Hospital, institution or
ZCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause n Accident ( (Homicide Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way, MD
Address
100 Park Stre t, Glens falls, NY
Death Certificate Filed District Numbe5601 Register Number
Gf; City, Town or Village Glens Falls 5 7/ to
❑Burial Date Cemetery or Crematory
February 12,2013 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
O —and/or Address
P. Hold
N
O Date Point of
NU Transportation Shipment
a by Common Destination
Carrier
Li Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
% y Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
r;::kii Address
r/
r Y/i
53 Quaker Road,Queensbury,NY 12804
-% 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 described above as indicated.
Date Issued 2-1 1 2 ) (3 Registrar of Vital Statistics (A) akA„),,Si.,
(sign re)
, District Number 5601 Place Glens Falls /N V /2 '�`/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
UJ Date of Disposition Z-i.3-t_3 Place of Disposition gnry et'''�iftw
(address)
W
N
o (section) (1 /number) (grave number)
pName of Sexton or Person in Charge of Premises rhr4
Z (please mt)
W
Signature ,` Title CaFtµ>4tde,
(over)
DOH-1555(02/2004)