Scripture, Victor 3 93
NEW YORK STATE DEPARTMENT OF HEALTH 1 `�Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Victor Michael Scripture Male
Date of Death Age If Veteran of U.S. Armed Forces,
5/14/2018 67 War or Dates 1970- 1971
Place of Death Hospital, Institution or
Z City, Town or Village Hartford Street Address 7364 State Route 40
Manner of Death n Natural Cause n Accident n Homicide Suicide n Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Eric A.Goe MD
Address
65 Elm Street Glens Falls NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
Entombment May 16,2018 Pine View Crematorium
II Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
v)
O Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier _
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W
Permission is h reby granted to dispose of the human remiiins escred ab a ; indicated.
Date Issued 5 t( 1C�
Registrar of Vital Statistics
VA&A-. (signature)
(�
District Number 51 S -t Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition SJIs jif Place of Disposition Est 6c.1o'-
W (address)
U)
(section) / (lot number) (grave number)
QName of Sexton or Person in Charge of Premises !�ti L 41
Z ((blease print)
W Signature a � Title (Ptf++Asit
(over)
DOH-1555(02/2004)