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Scurlock, George 5-9 V NEW YORK STATE DEPART V1ENT OF HEALTH Vital Records Section Burial - Transit Permit iigii Name First Middle Last Sex George Wesley Scurlock Male Date of Death Age If Veteran of U.S. Armed Forces, Mn 08/20/2016 83 yrs. War or Dates No • Place of Death Town of Hospital, Institution or Heritage Commons City, Town or Village Ti rnnt�Prncga Street Address Residential Health Care Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide nUndetermined 0 Pending Circumstances Investigation tu Medical Certifier Name Title Lt J. Gabler RPA-C Address Ticonderoga Health Center, Ticonderoga, New York 12883 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 3 ? ipii ['Burial Date Cemetery or Crematory 08/23/2016 Pine View Crematory []Entombment Address ©Cremation Queensbury, New York Date Place Removed Removal and/or Held 0,0 and/or Address w"` Hold id Date Point of Q Transportation Shipment C by Common Destination Carrier El Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address iiiiiii Permit Issued to Registration Number Name of Funeral Home Wilcox & Regan funeral home 01821 Er Address 11 Algonkin St. , Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above • Address Jr In 9. Permission is hereby granted to dispose of the human rem 'ns described above as indicated. Date Issued 8/2 2/2 01 6 Registrar of Vital Statistics t I . S�4 (sign ure) District Number 1 564 Place Town of Ticonderoga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 Date of Disposition f/231/f� Place of Disposition Pm to G/1'-.-tc�.7��j / !/ (address) til CC (section) (lot number) (grave number) Name of Sexton o erso Charge of Premises u1,4rl GQ, & 2 (please print) Signature Title 6/r-044-IV (over) DOH-1555 (02/2004)