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Iaconetti, Melissa - 4 iti3 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Melissa laconetti Female Date of Death Age If Veteran of U.S.Armed Forces, 05/02/2023 59 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p▪ Manner of Death 1=1 Natural Cause IllAccident El Homicide Suicide InUndetermined Pending W Circumstances Investigation W Medical Certifier Name Title G Bo Li MD Address 100 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 225 Burial Date Cemetery,Crematory or Facility Name 05/03/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held F— Hold Address N 0 CL Date Point of (p 0 Transportation Shipment Q by Common Carrier Destination o Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom r_ Remains are Shipped,If Other than Above N Address IE W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/03/2023 Registrar of Vital Statistics Megan.9lroBrng ctronrcaf Stgne42 (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— ''// Z Date of Disposition 5l�I 15 Place of Disposition ... E i1... L1_. W (address) W Cl) (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premises &---:‘,....+1- Z (pi se print) W rarat Signature Title ��n DOH-1555(07/18)p 1 of 2 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#