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Scoville, Theresa , 1 g (43 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Per it = Name First Middle Last Sex • Theresa Scoville Female Date of Death Age If Veteran of U.S. Armed Forces, 08/20/2017 55 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital 77 Manner of Death©Natural Cause El Accident El Homicide ID Suicide 0 Undetermined El Pending .w Circumstances Investigation ti. Medical Certifier Name Title Dean Reali DO Address . 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 444 � Date Cemetery or Crematory �� ❑Burial 08/22/2017 Pine View Crematory • ❑Entombment Address 2®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of [1 Transportation Shipment by Common Destination Carrier y Q Disinterment Date Cemetery Address • Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Stpo Box 500,Lake Luzerne, New York 12846 - Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Jx; 9r Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/22/2017 Registrar of Vital Statistics Rp6ertACurtis EkctronicalrySigned (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition g 1/4 In Place of Disposition f',,r v,w L.k,.i fors.-' (address) (section) /lot number) (grave number) • Name of Sexton or Person in Charge of Premises G/tr+ SE.,Ater' 7 (plea Je print) Signature II- Title t(`" 1 (over) DOH-1555 (02/2004)