Scott, Kylie z v Sila°
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:r:� Name First Middle Last Sex
r.
Kylie Leonora Scott Female
' Date of Death Age If Veteran of U.S. Armed Forces,
sr January 27, 2015 0 War or Dates
i:.::
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1om
X Natural Cause AccidentHomicide SuicideUndetermined Pending
CircumstancesInvestigation
Medical Certifier Name Title Anne Soruj,MD
:::1 Address
arr 100 Park Street,Glens Falls,NY
ADistDeath Certificate Filed
rict Number Register Number
:• City, Town or Village Glens Falls 5601 �
❑Burial Date Cemetery or Crematory
January 30, 2015 Pine View Crematorium
III Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O Date Point of
O. Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
▪ Permit Issued to Registration Number
in;K: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
:▪ :: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is herebyranted to dispose of the human remains described abov as i icated.
P l�/.�� ,L t
Date Issued 0/30 ZO/S Registrar of Vital Statistics ';d•� iC/
(signa ure)
*:.: District Number 5601 Place Glens Falls
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uui Date of Disposition 1/30)c Place of Disposition 1Mm L C vt�
W (address)
U)
O (section) (lot number (grave number)
G
Q Name of Sexton or Pers in Char a of Premises ��r„ Jtl
Z (please print)
W Signature 2- 1. Title frAg s W-,
(over)
DOH-1555(02/2004)