Scott Sr, James NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
iN Name First Middle Last Sex
James W. Scott, Sr. male
iiiiiiiii Date of Death Age • If Veteran of U.S. Armed Forces,
October 16, 1995 63 War or Dates Korea
„.....• Place of Death Hospital, Institution or
City, Town or Villa a Street Address f;l Pns Falls Hospital
9 City of Glens Falls
Natural Cause Accident Homicide Suicide Undetermined 0 Pending
Manner of Death ❑ ❑ ❑ ❑
Circumstances Investigation
Medical Certifierigii Name Title
0 Joseph C. Mihundukulasuriya MD
Address
52 Park Street, Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village City of Glens Falls 3 o/ .� ".'
Date Cemetery or Crematory
::::•nBu'rial October 18, 1995 Pine View Cemetery ___
Address
❑Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
t Hold
0 Date Point of
N❑Transportation Shipment
5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment
Date I Cemetery Address
€i Permit Issued to Registration Number
' Name of Funeral Home Regan and Denny Funeral Service, Inc. 01583
iiig Address
53 Quaker Road, Queensbury, New York 12804
..; : Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped, If Other than Above
Address
M.
ffi Permission is hereby granted to dispose of the human rc^sirs described above 2s intiLpated.
iiiiiiiiii Date Issued 7°_,ir, 3 Registrar of Vital Statistics %."-z-t - d,4--
(signature)
giii
ilii District Number ,6- Place
certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
f-
W Date of Disposition 10/18/9 5 Place of Disposition Pine View Cemetery Queensbury NY 12804
2 (address)
fa
Mohican 40-C 1
CC (section) (lot number) (grave number)
GName of Sex •- •r Person in Charge of Premises Rodney G. Mosher
z (please print)
W Signature „.1_,A., _v , Title Supt . .
DOH-1555 (10/89) p. 1 of 2 VS-61