Waldron, Scott * qq
NEW YORK STATE DEPARTMENT OF HEALTH 3b/
Vital Records Section Burial - Transit Permit
Name First bMiddle Last Sex
Scott K. Waldron Male
Date of Death ,Age If Veteran of U.S. Armed Forces,
May 19,2015 36 War or Dates
. Place of Death Hospital, Institution or
� City, Town or Village T/O Lake george Street Address 2716 State Route 9
` Manner of Death Undetermined Pending
Iti
Circumstances Investigation
w= Medical Certifier Name Title
' Michael Sikirica
Address
50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number Register umber
City, Town or Village T/O Lake George 5651
❑Burial Date Cemetery or Crematory
Entombment May 22,2015 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N 1 i Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
la
Permission is hereby granted to dispose of the human remains Cescri_bed above as indicated.
Date Issued S92 /
/ s- Registrar of Vital Statistics �'J77a-< /A
(signature)/
,=
,:::: District Number 5651 Place T/O Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z Place of Disposition �1,
Date of Disposition �J Z2�15 p „� � -��,,,�
W (address)
co)
Qre (section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises .,5,►
Z (pldase print)
W Signature 4
Title ((Um}tiW
(over)
DOH-1555 (02/2004)