Cross, Melvin gi3
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Melvin ' 0\6141 t) CS7-O SS Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/20/2017 70 War or Dates NA
F, Place of Death Hospital, Institution or
Z City, Town or Village Town of Queensbury,NY Street Address 24 Pine Cone Drive Queensbury,NY
p' Manner of Death 'A I Natural Cause L Accident n Homicide n Suicide n Undetermined n Pending
W Circumstances Investigation
W Medical Certifier Name Title
IC'1 Dr Mihindu
Address
20 Murray St.Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Town of Queensbury,NY SUS', 1`t 1.0
❑Burial Date Cemetery or Crematory
❑Entombment 11/22/2017 Pine View Crematory
Address
Ni Cremation Queensbury,NY
Date Place Removed
ZZ I I Removal and/or Held
2and/or Address
H Hold
u)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
ii
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford 01443
Address
53 Quaker Rd.Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
2 Address
IZ
11.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t k-a a'"a0Il Registrar of Vital Statistics - 124Al. tea..Q c��
(signature)
District Number 3 l5 7 Place Q U t c I S b Jj
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W Date of Disposition //On tY) Place of Disposition fl.ti✓ cr e,{F---
W (address)
N
O (section) (lot num ) (grave number)
p• Name of Sexton or Person in Charge of Premises j�„ , s.►1,4C
Z please print)
W Signature 4 Title (MIA o__
(over)
DOH-1555(02/2004)
Town of Queensbury
IOWA
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Melvin Cross
were cremated on November , 24 20 17 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death November , 20 20 17 Age 70
(Month) (Day)
Funeral Home Regan Denny Stafford Registered No. 893
.„,‘
(Authorized Signature)
CROSS •
-- O
Lot No.
Address Harry & Bernice Cross Section:io.
Owner 17 Oak St., 'lens Falls, N.Y. Plot Oneida
Date 3/27/80
35 Superficial ft. @ $125.00- sc.4„,; �c�e„6;
Location Bounded on the North byMatteson, East byArnold, South byRace, West b We b
Y
Corner Posts
Remarks
Deed.No. (and changes) 1583
Payment Record Paid in full 3/�700
A
Form No. 01
Record of Interments
ero 6, • S'-..?3
Bernice Cross 4/4/201R 1 5 1:biry-/ ac. SS ' D3 913
2
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David M. Cross (iith/80) 1 7
4 Melvin Cross 11 /29/2017 (Cremain) I 8
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CROSS
NAME Melvin Cross Age: 70
Lot Owner: Harry & BerniceCross
Lot# 41B Oneida Grave# 4
Case: Plastic Urn
Died: 1 1 /2 4/2 01 7 Interred:1 1 /2 9/2 01
Funeral Home:
Regan, Denny, Stafford
Cemetery:
Pine View Cemetery