Moon, Johanna H fr2L
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NEW YORK STATE DEPARTMENT OF HEALTH /
Bureau of Vital Records f Burial - Transit Permit
Name First Middle Last Sex
Johanna H.Moon Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/21/2022 86 Years War or Dates
WCityPlace of Death Hospital,Institution or
,
Town or Village Glens Falls Street Address Glens Falls Hospital
e Manner of Death ID Natural Cause Accident 0 Homicide Suicide EVndetermined Pending
Circumstances Investigation
V Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 646
Burial Date Cemetery,Crematory or Facility Name
12/23/2022 Pine View Crematory
Entombment— Address
EICremation Queensbury,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
NHold Address
i Date Point of
to ETransportation
;S by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ill Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Alit
Address
s' 407 Bay Rd,Queensbury,New York 12804
:) 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 remains described above as indicated.
Date Issued 12/22/2022 Registrar of Vital Statistics Megan Nolin(ECectronica1Cy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /z 2y04,74 Place of Disposition 6, .Je 1i:t,;,3 Ci—e- k
(address/
W " ,
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge o remises 1 \a r/10,- ._) i/S 'l
,-, (please pant)
Signature G%!fY Title 1 E' -
DOH-1555(07/18)p 1 of 2
• • 1 y,
1)iF 33
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on : , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#