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Moxham, Colin Michael it T NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Colin Michael Moxham Male Date of Death Age If Veteran of U.S.Armed Forces, 01/16/2021 32 Years War or Dates 1,.. Place of Death Hospital,Institution or W City,Town or Village Hudson Falls Village Street Address 35 Elm Street,Hudson Falls Village,New York 12839 p' Manner of Death ❑ Natural Cause El Accident ❑Homicide D Suicide ❑Undetermined ©Pending W U Circumstances Investigation W Medical Certifier Name Title CI Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 1 ❑Burial Date Cemetery,Crematory or Facility Name 01/20/2021 Pine View Crematorium 0 Entombment Address 0 Cremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 a Date Point of Cl) ❑Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above Address C W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2021 Registrar of Vital Statistics Cynthia Bartin(ECectronica1TySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ gK C Z Date of Disposition ,�2Z i'7( Place of Disposition ` W (address) !iJ N CC (section/ number) (grave number) 0 Name of Sexton or Person in Charge of P ises r" �— S ...AI Z (pleaseprint/ /� liJ Signature s Title ` 147VvZ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 4 114 6 Receipt Human remains of a delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '