Loading...
Paris, Melissa NEW YORK STATE DEPARTMENT OF HEALTH ' 4 c Vital Records Section Burial - Transit Permit Name First Middle Last Sex Melissa Jane Paris Female Date of Death Age If Veteran of U.S. Armed Forces, January 25, 2017 54 War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation Manner of Death Friu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending Ili (a Circumstances Investigation I Medical Certifier Name Title Roslyn Socolof, M.D. Dr. Address 100 Broad Street Glens Falls, NY 12801 Ci o r Village Filed Dj ric-S umber Reaster Number Ci Town�r Village Queensbury � 1 ( U ❑Burial Date Cemetery or Crematory January 26, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold 1 Date Point of O❑Transportation Shipment by Common Destination Carrier _ Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom e Remains are Shipped, If Other than Above Address i I Permission is hereby granted to dispose of the human re a s described a ov as indicated. Registrar of Vital Statistics /� O r?.� Date Issued�j l I�p� � � ��� l ! J (signature)____ District Numberocr Place I CjL3t-6- (4CQL)....12s2. 10,- --f I certify that the remains of the decedent identified above were disposed of in accordarfvv th this permit on: Date of Disposition 01/26/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) w (section) / (lot number) L :"s t (grave number) Name of Sexton or Person in Charge of Premises � St Y1(please print) Signature a Title I( m011-01- (over) DOH-1555 (02/2004)