Elna S. MelvinNM
104 Dennis Drive • Lexington, Kentucky 40503 • (606) 278-8508
Blair Cemetery
ATTN: Pat Long
218 South 16th Street
BlAIR, Nb 68008
Mr. Long,
Per our phone conversation, enclosed please find a check
in amount of $ 80.00 for interment of the cremains of
ELNA SMITH MELVIN.
Thank you for your help in this matter. I am,
Sincerely yours,
M -
Robert L. Pruitt
hlp/RLP
Robert L. Pruitt
Funeral Director
THE LEXINGTON CEMETERY CREMATORY
833 West Main Street Lexington, Kentucky 40508
Phone 255-5522
CERTIFICATE OF CREMATION
This is to certify that the remains of ......MrS Elna S . Melvin
...............................
who died....._9/5/9.2........................... 9/8/
were cremated on...........................................92....
at the Lexington Cemetery Crematory.
Cremation No.....................2758
THE LEXINGTON CEMETERY CREMATORY
...........................:....%7 .
(Authorized Signature)
VS -34 COMMONWEALTH OF KENTUCKY
(Rev. 11/91) Department for Health Services
Registrar of Vital Statistics See back of form for instructions
Please Press Hard
Making Three Copies PROVISIONAL REPORT OF DEATH
(A)
ELNA SMITH MELVIN AM
Name Date of Death 9-5-92 _ Hour 5:45 AMX&U
FAYETTE FAYETTE Age, 88' Race W Sex F
County of Death County of Residence
Facility or location of Death 121 FOREST AVENUE, #36, LEXINGTON, KY'
(Include City/State)
Medical Certifier of Certificate: TERENCE GUTGSELL M D 1401 HARRODSRuEa RD T FXTrTGTON, KY 40504-3751
Address
Facility Notes:
Blood and Body Fluid Precautions Advised? YES XXX_ NO Blood and body fluid precautions should be
observed for any post-mortem procedure regardless of diagnosis.
KENTUCKY ORGAN DONOR AFFILIATES (KODA) -- (800) 525.3456
Contraindication to Donation (Ch@ck all that apply) Over age 70'_X Documented Sepsis _ Transmittable disease
KODA Contacted? Yes No XXX If No, Give Reason
Relationship of Family Member Approached:
If Family Not Approached, Why?
(B) Authorization is hereby gran.?ed to -HOME HEALTH CARE NuRSTNr' SFRtrTr_Er•
Facility Name
to release the remains of the above named to PRUITT' S FUNERAL HOME
Funeral Home
for the purpose of transportation and/or disposition.
Signature Next of Kin
CLAIRE DIXON-CONDER
Signature of Local Registrar, Deputy Regist
r Hospice Nurse
' ` Witness
(C) I, representing ('U i -l- 6 r r ..,ne cJ ( Dn-Ne—
hereby accept the remains of,the above named and agree to secure and file a complete and satisfactory certificate
of death within the time limits established by KRS 213.,,
Signature Address
�xI r- q q0503
City/State'
(D) I am aware of the circumstances surrounding the death of the above named person and hereby authorize cremation
u6Lof the remains. P�,n,,^,1" oer' of Count Date G ' 5- q �
Y
(E) Remains of the LF�()NGTQN named were
cremated
consigned to on �?
�, Name of CemeterylCrematory
LEXINGTON, KENTUCKY 40508
Address D,
Signatu a (Sexton or Person in Charge)
White Copy—Must accompany deceased Yellow Copy—Health Department in the County of Death Pink Copy—Facility Copy