Livingston, Scott ,. ` # 7t3
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Name Firs Middle L sti Sex
cott M Livngston Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/26/2018 58 years War or Dates
t-- Place of Death Hospital, Institution or
W City, TAM& ,MM C Glens Falls Street Address Glens Falls Hospital
a Manner of Death Lnr7i Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
W Circumstances Investigation
tu Medical Certifier Name Title
i Christopher D. Hoy M. D.
Ad1beiscarey Road Queensbury, NY 12804 '
Death Certificate Filed District Number Register Number
City,-TdGW&la
Glens Falls 5601 156
I•'<❑Burial • Date Cemetery or Crematory•
03/28/2018 Pine View Cematory
❑Entombment Address
`. 3Cremation Queensbury, Ny •
Date Place Removed
2❑Removal and/or Held
and/or Address
tr. Hold
{ Date Point of
tl Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
• Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2018 Registrar of Vita! Statistics LA)CJ Y 1,�,v.
RKr
(si ature)
District Number 5601 Place Glens Falls,Ary
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II• Date of Disposition 3)1S(Iq Place of Disposition .PNtU -
a (address)
w
rc (section) /f (lot number) (� (grave number)
• Name of Sexton or Person in Charge of Premises . :14
fi d?::, Signature { ease print1-'
Title /124•ft+n ITYL
(over)
DOH-1555 (02/2004)