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Moulton, Donald D 111 NEW YORK STATE DEPARTMENT OF HEALTHF Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Donald D Moulton III Male Date of Death Age If Veteran of U.S.Armed Forces, 11/21/2023 43 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death Undetermined Pending W Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 540 Burial Date Cemetery,Crematory or Facility Name 11/22/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held F- Hold Address 0 Date Point of t/) Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2023 Registrar of Vital Statistics Megan Nolin(Electronically 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: IF— Z Date of Disposition //—2 7-2o23Place of Disposition j h Q`j t Gce W 2 (address) W CC N (section) t (lot number) (grave number) aName of Sexton or Pe n i harge of Premises 4 IQ pi 6� c"{'LL Z (please print) IlJ Signature Title G co ✓►`4,47 P.�c DOH-1555(o7/t8)pi of 2 l ,. Er r ^96 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#