Moffitt, Timothy 4- i
NEW YORK STATE DEPARTMENT OF HEALTH 1.0F
11
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Timothy Moffitt Sex
Date of Death Male
I Age I If Veteran of U.S.Armed Forces,
06/15/2022 56 Years War or Dates
i.., Place of Death Hospital,Institution or
pZ City,Town or Village Corinth Town Street Address Capital District DDSO
Manner of Death Natural Cause ❑Accident Homicide Suicide Undetermined W Pending
QV Circumstances Investigation
MedicalCertfier Name Title
Paul Byron MD
Address
500 Balltown Road,Schenectady,New York 12304
heath Certificate Filed Town Of Corinth J District Number Register Number
ity,Town or Village 4553 111
Burial Date Cemetery,Crematory or Facility Name
'_' 06/16/2022 Pine View Crematorium
Entombment
_ Address _.
IICremation Queensbury Town,New York
.Donation
ZII Removal Date Place Removed
f= and/or and/or Held
N Hold Address
0
O. Date Point of
Cl)a Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
II Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
i. . Remains are Shipped,If Other than Above
2 Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/16/2022 Registrar of Vital Statistics Bretufa L Petis gCectronicatfySigned)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ad......_.Date of Disposition (o (11it Place of Disposition
.7,41
W
2 /address/
W
N (section) A
(lot number) (grave number)
/
CC S Name of Sexton or Person in Cha f Premises Lr1
Z 1p ase print)
W Title Irtfifn ite
Signature
DOH-1555 lo7/18)p 1 of 2
8
Public Health Law Sec. 4145(2b) 0 1 5 ° 9
Receipt
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f , / r
Human remains of ' ' - r , ` delivered on , 2Q'''/"`�.__.
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Pine View Cemetery Representing the funeral home named on burialyermit
Official Funeral Directors Reg.or License#-i" -----,_' , > -/'