Longtin, Scott NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Scott K. Longtin Male
Date of Death Age If Veteran of U.S.Armed Forces,
July 7, 2016 43 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Saratoga Springs Street Address Saratoga Hospital
1) Manner of Death El Natural Cause ill Accident ' 1 Homicide n Suicide Undetermined n Pending
Circumstances Investigation
U Medical Certifier Name Title
Dr. Nicoleta Daraban, M.D. Dr.
a Address
211 Church Street, Saratoga Springs, NY 12866
Death Certificate Filed District Numtte Register Nu er
City,Town or Village Saratoga Springs
❑Burial Date Cemetery or Crematory
Pineview Crematorium
n Entombment Address
Q Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
I' Hold
Date Point of
0 111 Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address 4
n11 Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
8. Address
Permission is here y gr nited to dispose of the human re c " ed ab9v indica d.
Date Issued ("L ((,, Registrar of Vital Statistics
(signature)
District Number S—DI Place Saratoga Springs,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7/i 7/6, Place of Disposition Pineview Crematorium
2 (( (address)
(I)
0 (section) t number) (grave number)
O Name of Sexton or P rson in barge of Premises
(please print)
Signature � � Title G-lcyyi %—
(over)
DOH-1555 ( 2/2004)