Stradford, Melva NE YORK STATE DEPARTMENT OF HEALTH It Si 6
• Vital Section Burial - Transit Permit
Name First Middle—� Last Sex
Melva Jean Stradford Female
Date of Death Age If Veteran of U.S.Armed Forces,
October 9, 2011 57 War or Dates NO
2 Place of Death Hospital, Institution or
W City,Town,or Village Clemons Street Address Residence
G Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Max Crossman MD
0 Address
65 Poultney Street Whitehall New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Clemons 5 752— e
❑Burial Date Cemeteryor Crematory
October 17, 2011 Pineview Crematorium
❑Entombment Address
❑R Cremation Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
l' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a ❑ Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
a
Permission is hereby granted to dispose of the human remains described above' as indicated.
Date Issued 1O//3/,/ Registrar of Vital Statistics 1 y�'L�.vu>I't IL w i M�
(signature)
District Number _6'75 ,2_, Place Clemons,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition lb lit;I it Place of Disposition Pineview Crematorium
2 (address)
0
fY
0 (section) at,
_ 1 (lot numbery~ (grave number)
0Name of Sexton or Person i Charge of Pr ises o}�OK� �ev+KIt
W I (please print)
Signature fL
Title CQrrmAT(AL
A _
(over)
DOH-1555 (02/2004)