Moulton, Stanley NEW YORK STATE DEPARTMENT OF HEALTH ' ,r,. ;�`' (, L
Vital Records Section Burial - Transit Permit
Name First Stanley Middle Last Sex
J Moulton Male
Date of Death ' Age T If Veteran of U.S. Armed Forces,
3/20/2012 59 War or Dates no
Place of Death I Hospital, Institution or
CitXWt�a7 Glens Falls _ 1 Street Address Glens Falls Hospital
Mariner of Death ou Natural Cause Q Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher Jackson PA
1 Address
Indian Lake,NY
Death Certificate Filed 1 District Number ` Registerer
City. R Glens Falls ' Sh01
Date Cemetery or Crematory
❑Burial i 3/26/2012 Pine View Crematory
Address
ED Cremation! Queensbury,NY
Date Place Removed
Z and/or Removal and/or Held
Address
to Hold _
a Date ' Point of
Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment { Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
`;:. Address
6357 State Rte. 30, Indian Lake,NY 12842
Name of Funeral Firm Making Disposition or to Whom
C" Remains are Shipped. If Other than Above
Address _
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/2 7)J 2 Registrar of Vital Statistics L 3 C .'�. t.
(signature)
District Numbei5667 Place 61/4'r1.f -//4 i� / 2a'o/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1-111~)1 Place of Disposition 12.,.•V uw crt,ivef or Ivn
2 (address)
i11
N
O
(section) / - (lot number (grave number)
G Name of Sexton or Person in Charge of remises r;i�r�l�er o4.40
AL (please print)
ta Signature Title CQ,r-iY)I}-bef--
DOH-1555 (10/89) p. 1 of 2 VS-61