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Haworth, Scott NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section N Burial - Transit Permit Name First Middle Last Sex Scott Warren Haworth Male Date of Death Age If Veteran of U.S. Armed Forces, October 12,2013 46 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Town Of Keene Street Address Round Pond Trail p Manner of Death Natural Cause Accident I I Homicide X Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title O Francis W.Whitelaw Address 60 Maple Lane,Bloomingdale,NY 12913 Death Certificate Filed District Number Register Number City,Town or Village Town of Keene 1555 ❑Burial Date Cemetery or Crematory ElEntombment October 16,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd.,Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address Hold N O Date Point of NTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Clark,Inc. 01075 Address 2310 Saranac Ave.,Lake Placid,NY 12946 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address W tL Permission is hereby granted to dispose of the human remains described above as icated. Date Issued 10-16-2013 Registrar of Vital Statistics eta1 .& IOtt (signature) District Number 1555 Place Town of Keene H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition io 1111E5 Place of Disposition RReVleu `A~ W (address) N Ct (section) (tot number) (grave number) pName of Sexton or Person in Charge of Pre ises W (please print) ILSignature !/ Title Ct /Wi . (over) DOH-1555(02/2004)