Ash, Melody Elizabeth # 3, —)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Melody Elizabeth Ash Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/27/2022 51 Years War or Dates
1_, Place of Death Hospital,Institution or
W City,Town or Village Argyle Town Street Address 4185 County Route 48 Road,Argyle Town,New York 12809
p Manner of Death ❑x Natural Cause Accident ❑Homicide ESuicide Undetermined ❑Pending
W
V Circumstances Investigation
W Medical Certifier Name Title
CI Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 21
Burial Date — I Cemetery,Crematory or Facility Name
® 05/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
O❑Removal Date Place Removed
and/or and/or Held
I- Hold Address
t)
0
O. Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
1=1Rei nterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1.- Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics Shelley Mckernon(Electronically Signed)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition S-14 lit_ Place of Disposition F,,,,,,,AL 4,..k.....__--(address)
W
NCC (section) (grave number)
• Name of Sexton or Person in Charge of Premises A,, . (,,,,Ln:mber)
! print)
Z l gyp , d'/�
W t% Title d 1''t�1M1Hf"N�-
Signature
DOH-1555(07/18)p 1 of 2
A Pt"t
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#