Scoville, Shirley NEW YORK STATE DEPARTMENT OF HEAL a-H Z O5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley Elizabeth Scoville Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 17, 2011 89 War or Dates
Place of D, ath Hospital, Institution or
-1 Ci Town r Village H `r:-i A t Street Address 200 Reservoir Road
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide E Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
F1 Medical Certifier Name Title
Christopher D. Hoy, M.D. Dr.
Address
nF.
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number s 2 Register Number
City, Town or Village /� tp
❑Burial Date Cemetery or Crematory
April 19, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
1 ❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
`, Permit Issued to Registration Number
`▪ Name of Funeral Home M.B. Kilmer Funeral Home 01097
4 Address
w 136 Main Street, South Glens Falls NY 12803
▪ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rema s described abov as indicated.
Registrar of Vital Statistics
• Date Issued �/� // 9 q.'
(signature)
oz District Number 6602. Place �.-/ 0---LiAn i (M-efAZei—‘?_f
--
'a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• ': Date of Disposition 04/19/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb (grave number)
• Name of Sexton or Per n in Charge f Premises i�r,s}opf snhl
i (please print)
Signature Title Cfammg.,
(over)
DOH-1555 (02/2004)