Spires, Melvina NEW YORK STATE DErriKTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Melvina W Spires Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 27, 2010 j 88 War or Dates No
Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address 61 Bluebird Rd. Town Of Moreau
iii
0 Manner of Death X Natural Cause 1 Accident Homicide Suicide Undetermined Pending
WCircumstances Investigation
w Medical Certifier Name Title
0 Anthony Petracca
Address
3 Iron Gate, Glens Falls,NY 12801
Death Certificate Filed District Number ' Register Number
City, Town or Village Town Of Moreau . J`4,2• , /9•
❑Burial Date Cemetery or Crematory
December 29, 2010 I Pine View Crematorium
❑Entombment
Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
9 Z I I Removal Address and/or Held
and/or - - - - --- --- __ -
H Hold
0 Date Point of
co Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
i
Reinterment Date j Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Sullivan Minahan & Potter _ _ 01675
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I.- Remains are Shipped, If Other than Above
Address - - - -- _-------_ ----
C
--
a.
Permission is hereby granted to dispose of the human remains described above s indicated.
Date Issued /,;-4//D' Registrar of Vital Statistics Ber_tee.,--F__• -,
(signature)
District Number 445G,2_• Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition afar 3, jail Place of Disposition Plitt J,it.+ ertAXC.{0*w .,
W (address)
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(section) 7) a (lot number) (grave number)
QName of Sexton or Person in Charge o, Premises `/ ,.,St It r Jt 1 tf
Z / , (please print)
W
Signature [ �^ Title Cl?eM Ftt U(-
(over)
DOH-1555(02/2004)