Moore, Dan Howard L.
97."'--
41- 557
NEW YORKSTATE DEPARTMENT OF HEALTH F--'--•') Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dan Howard Moore Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/04/2022 64 Years War or Dates . .
H Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Old River Road,Johnsburg Town, New York 12853
LU
p Manner of Death 0n
Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
VI 1iCircumstances Investigation
IL1 Medical Certifier Name Title
a Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 32
Burial Date Cemetery,Crematory or Facility Name
12/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
U)
0
O. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
a Address
Ilz
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
g Date Issued
12/06/2022 Registrar of Vital Statistics Jean M Comstock(Electronically Signed)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /
Z Date of Disposition l zl i i Z Z Place of Disposition F",I /
ILI (address)
LLI
CCCC (section) (lot number) 514,44
(grave number)
OO Name of Sexton or Person in Cha a of Premises A
l7
le se print)
z (p P /
W Signature Title G 161/41ftAt
DOH-1555(07/18)p 1 of 2
i * p
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#