Moran, John If
NEW YORK STATE DEPARTMENT OF HEALTH Jr A vl l7
Vital Records Section Burial - Transit Permit
�3h Name First Middle Last Sex
John Joseph Moran Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 30, 2012 81 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehabilitation Center
Manner of Death 0Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
twi Circumstances Investigation
W Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Dumber
t
, City, Town or Village to 5 i 0 b
❑Burial Date Cemetery or Crematory
August 31, 2012 Pine View Crematory
;' ❑Entombment Address
®Cremation 'Uuacer Road Queensbury,NY 12804
Date Place Removed
1. Removal and/or Held Pine View Crematory
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
4. ❑Transportation Shipment
by Common Destination
Carrier
IIIDisinterment Date Cemetery Address
ElReinterment 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 r mains d scribed abovet s indicated.
Date Issued 5/30/ Registrar of Vital Statistics � `21 't�
��-�� (signatc�ure
District Number 1,12 S-) Place (`�-�,Q ,r; -y — M b� 7 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/31/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
a
(section) /� (lot number) (� (grave number)
Name of Sexton or Person in Charge of Premises "f►: r Sh.4�
(pl ase print)
_: Signature Title ClZgAr1/4
(over)
DOH-1555 (02/2004)