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Amadeo-Moffitt Melissa M 01/4 re' ' ti 1,1 [ Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Melissa M.Amadeo-Moffitt Female 4 kx; Date of Death Age If Veteran of U.S.Armed Forces, '/.' 05/07/2021 44 Years War or Dates Place of Death Hospital,Institution or 2 City,Town or Village Glens Falls Street Address Glens Falls Hospital W. Manner of Death ©Natural Cause 0 Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title 0 Asim Chaudry MD Address ,,„ 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 209 L j Burial Date Cemetery,Crematory or Facility Name 05/12/2021 Pine View Crematory Entombment Address , W Cremation Queensbury Town,New York ' El Donation ZDate Place Removed O El Removal and/or Held and/or Hold Address G a Date Point of 3o L j Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number ti`' Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. -',, Date Issued 05/11/2021 Registrar of Vital Statistics 1Z9bertAndrew Curtis(ECectronicallySigned) (signature) r ;; District Number 5601 Place Glens Falls, New York '; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F-e � Z Date of Disposition SOIL( 7( Place of Disposition —1'I+ucL e------ Ills (address) W NCC (section) (10 number) (grave number) .p'� ��l,fT Name of Sexton or Person in Charge of Pr isesI n,j(pleasepri t) z al Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 7' Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#