Moon, Eugene R 77
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Eugene R.Moon Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/16/2021 88 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
WQ Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 10
Burial Date Cemetery,Crematory or Facility Name
03/18/2021 Pine View Crematory
0 Entombment Address
lCremation Queensbury Town,New York
ElDonation
z Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
CO ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/18/2021 Registrar of Vital Statistics Kathleen C. Lorah(Electronically Signed)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ �^�
W Date of Disposition algal$ Z Place of Disposition ,F1
2 (ad ress/
W
(section) (lot nujr) (grave number)
Name of Sexton or Person in Charge of Prem'ses
Z (please print)
W Signature Title
DOH-1555(07/18)p 1 of 2
p
Public Health Law Sec. 4145(2b) J 1 4 4?
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#