Melucci, Kathleen ci
NEW YORK STATE DEPARTMENT OF HEALTH ,s. It C `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen Dorothy Melucci Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 7, 2012 65 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause Accident Homicide Suicide Undetermined ri❑ Pending
W; Circumstances Investigation
W Medical Certifier Name Title
Cl Mathew Varughese, MD Dr.
IAddress
Glens Falls Hospital Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
City, Town or Village 5601 7 / "2
❑Burial Date Cemetery or Crematory
May 11, 2012 Pine View Crematorium _
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date I Place Removed
z ri Removal I and/or Held
and/or Address
Hold
U) Date Point of
0 Transportation Shipment
IA by Common Destination
Oi Carrier
Disinterment Date Qemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W,
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 f 9 f/7 Registrar of Vital Statistics LACk M Q t�,��
s _0 _ (signature)
District Number 5601 Place(g
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition j lii't1. Place of Disposition xlikaL Ct' G6ro..,
2 (address)
Wto
''
c' (section) 4 (lot numb? (grave number)
0
z Name of Sexton or P son in Char a of Premises kctlft` _)t\Ktt
` 1 (please print)
z
Ui Signature Title _ GaI,y.U�1Pi_bQ
(over)
DOH-1555 (02/2004)