Scoville, Melissa NEW YORK STATE DEPARTMENT OF HEALTH 4 Ub
Vital Records Section 1 • Burial - Transit Permit
Name First Middle Last Sex
Melissa Joy Scoville Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/t0�/20 �17 years War or Dates
F- Place o eat12 Hospital, Institution or
2 City, To vYV Street Address
1 �� X Glens Fall. Clcns I1s Ho it^1
W Manner 61 illI �t Natural Cause ,1 Accident ❑Homicide ❑Suicide Undefermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
C
Address' Scidmore Coroner
Chestertown. N Y
Death Certificate Filed District Number Register Number
City, TovXV�X Clcns Falls •
562
❑Burial Page— Ceme ery�5601 or Crematory
❑Entombment Address 2/13/2012 Pine View Crematorium
Hm❑cremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9 ❑and/or Address�
Hold
Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home 01078
Address
136 Main Street South Glens Fails, N Y 1781)3
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
,,,,,,ill
• Permission is hereby granted to dispose of the human remains descri d above s in a ed.
<> Date Issued 12/10/2012 Registrar of Vital Statistics .eh A.
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition (1-I ii')Z Place of Disposition P I r1 i/ ���� � (=�1�
2 V (address)
111
i
1X (section) . (£i)/, .1
tuber) (grave number)
CI Name of Sexton Pers in C►= .. of Premises ��0 i/ I
z (please print) ^'
Signature Title � � /�,�
(over)
DOH-1555 (02/2004)