Russell, Melanie Mary NE
W YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Melanie Mary Russell Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2023 62 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 63 White Birch Estates, Moreau Town,New York 12828
pManner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined riPending
Circumstances Investigation
W Medical Certifier Name Title
Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 70
Burial Date Cemetery,Crematory or Facility Name
12/15/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
F N Hold Address
0
O. Date Point of
N Transportation
p by Common Shipment
Carrier Destination
oDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2023 Registrar of Vital Statistics Brenda.futter(ECectronica(CySigned)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
W Date of Disposition ta.LS•o73 Place of Disposition at j Kz g
2 (address)
Q (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premises •Ik---r-)i-xt rYZ ��'
Z (please print)
W Signature Title J „c�rvJ"1�G S1
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) -' `i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
RUSSELL
Owner 0 .
Melanie Russell
Address Plot
63 White Birch Estates, Fnrt Edward, NY 12828 Seneca
Phone # Lot #
518-222-0404 14 E
Deed # Date
4354 10.31 .22
Cost Foundation Y - N
$600.00
Location North-Hermance
West-Rawson
South-Schule
East-Russell
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
.„„)PINE VIEW CEMETERY,---X
SIGNATURE:. 7.1 &-e-4- DATE:42 .2. -----
SIGNATURE: DATE:
Record of Interments
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RUSSELL
NAME Melanie Russell ge: 62
Lot Owner: Melanie Russell
Lot# Seneca 14 E Grave# 1
Case: Concrete
Died: 1 2 . 1 0.2 3 Interred:1 2.2 5.2 3
Funeral Home: Baker FH
Cemetery: Pine View