Scofield, Hunter NEW YORK STATE DEPARTMENT OF HE! H
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hunter F. Scofield Male
Date of Death Age If Veteran of U.S. Armed Forces,
7/5/2 01 4 15 War or Dates no
1 Place of Death Hospital, Institution or
ZCity, Town or Village Lake Luzerne Street Address River Road
Manner of Death L. Natural Cause ®Accident 0 Homicide D Suicide D Undetermined El Pending
ttf Circumstances Investigation
.Lj Medical Certifier Name Title
L Michael Sikirika M.D.
Address
Waterford, NY
Death Certificate Filed District Number Register Number
City, Town or Village Lake Luzerne 5656 9
'i< Burial Date Cemetery or Crematory
7/10/2014 Pine View Crematory
; Entombment Address
,WiaCremation Queensbury, NY
Date Place Removed
2 Removal and/or Held
2❑and/or Address i,;,;
CO
Hold
0 Date Point of
Transportation iV#❑T tti -
Shipment
OS by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IXU
IL Permission is hereby granted to dispose of the human re ins descri e above as indicated.
Date Issued —7 r4-- 1 H Registrar of Vital Statistic
(signature)
Ei District Number67 5(10 Place LG
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k /�
III Date of Disposition 7-I 1-(+1 Place of Disposition ?nt.I— C.r^'40r"-
2 (address)
ILI
VI
CC (section) i - (lot nu ber) (grave number)
ci Name of Sexton or Person . Charge of Premises � "i4
2 (please print)
Signature L Title �"
9
(over)
DOH-1555 (02/2004)