Moore, Melvin NEW YORK STATE DEPARTMENT OF HEALTI ft 77Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Melvin B. Moore Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 31, 2015 60 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 215 Broadway Apt 1
Manner of Death❑ Natural Cause X❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Number C ri ,,-f Registc Number
ii City, Town or Village Fort Edward J oV't
u�'❑Burial Date Cemetery or Crematory
April 10, 2015 Pine View Crematory
❑Entombment Address
• ®Cremation Quaker Road Queensbury,NY 12804
':-,.41,k Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
f, ❑ Disinterment
Date Cemetery Address
-
❑ Reinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human r ins slescribecilibove s indicated.
Date Issued 14 lq 115 Registrar of Vital Statistics r /
--. 1 (signature
▪ District Number5/ 55 Place /0-1.0iL 06 i'V c-'E ET
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-` Date of Disposition 04/10/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in C arge of Premises y +a�
rr k.
(phase print)
--,, Signature *�-�� rRna�
9 Title
(over)
DOH-1555 (02/2004)