Moffitt, Arthur V CLF
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Arthur V.Moffitt Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/07/2022 69 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 3372 State Route 9 Route A,Lake George Town,New York 12845
`p Manner of Death II Natural Cause Accident Homicide OSuicide Undetermined riPending
U Circumstances Investigation
LU Medical Certifier Name Title
Aimee Clinton NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 21
Burial Date Cemetery,Crematory or Facility Name
12/10/2022 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
F_- Hold Address
N
0
d Date Point of
Cl) Transportation
by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/09/2022 Registrar of Vital Statistics Patricia R,Mc4(inney-Sc&uster(ECectronicaltySigned)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit oil:
Date of Disposition iZ—A9—z,)zy Place of Disposition e.iie f j��,.t) �f.�u r
(address)
W
CC CC (section) (lot numb ) (grave number)
0 Name of Sexton or Person in Char a of Pre ' es ��ylz/d.J)
Z / l (please print)
W Signature Title
DOH-1555 07/18)p t of 2
zoo 17' .-7
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#