Scott, Theodore NEW YORK STATE DEPARTMENT OF HEALTH it 717'
Vital Records Section J- -a Burial - Transit Permit
Name First Middle Last Sex
Theodore N Scott Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. April 28, 2014 7/ War or Dates /ne - /963
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
G Manner of Death ❑Natural Cause ❑ Accident ❑Homicide ElSuicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Max Crossman MD
a Address
Whitehall Health Center, Poultney St., Whitehall, New York 12887
Death Certificate Filed District Number Q Register Number
City,Town or Village Whitehall 5 O
701 5
❑Burial Date Cemetery or Crematory
May 1, 2014 Pineview Crematorium
❑Entombment Address
J Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
F Hold
0 Date Point of
0 ❑Transportation Shipment
a. by Common Destination
Carrier
Date Cemetery Address
a ❑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
2 Remains are Shipped, If Other than Above
X
W Address
O.
Permission is hereby granted to dispose of the human r ains,described above as indicated.
S Date Issued 11 1 ti q Mika(
Registrar of Vital Statistics Q •
(signature)
District Number 5'7a '' Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 05/01/2014 Place of Disposition Pineview Crematorium
2 (address)
W
N
0 t (section) (lot numbepr� (grave number)
Name of Sexton or P rson in Charge of Premises dr,44,„ Jt0.4+-
Z lease print)
W 6fL__
Signature Title Celia�r��y�
(over)
DOH-1555 (02/2004)