McLaughlin, D. Scott NEW YORK STATE DEPARTMENT OF HEALTH t ip b L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
D. Scott McLaughlin Male
Date of Death Age I If Veteran of U.S. Armed Forces,
September 5,2012 84 War or Dates No
tPlace of Death Hospital, Institution or
. : City, Town or Village Queensbury Street Address 1966 Ridge Rd.
ci Manner of Death ❑X Natural Cause n Accident El Homicide ❑Suicide ❑Undetermined n Pending
U3 Circumstances Investigation
Medical Certifier Name Title
Donald Merrihew Dr.
Address
319 Bay Street,Queensbury,NY 12804
Death Certificate Filed District Number Regisser,A,umber
City, Town or Village Queensbury 5657 lI ��
❑Burial Date Cemetery or Crematory
❑Entombment September 10, 2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
r- Hold
ro
O Date Point of
N n Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
.; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
`'-: 407 Bay Road,Queensbury, NY 12804
?� Name of Funeral Firm Making Disposition or to Whom
N+ Remains are Shipped, If Other than Above
aAddress
• Permission is hereby granted to dispose of the human r ains described ove s indicated.
d Date Issue del '1 /c ) i - Registrar of Vital Statistics `�1 . c v y L 1
(signature)
District Number 5657 Place Queensbury .r1 I acio9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z C/'
w Date of Disposition 't-II-12_ Place of Disposition {�„,0tc�„! ...t'o rw _, , .
(address)
W
CO
W (section) (lot numbe� (grave number)
pName of Sexton or Person in Charge f Premises 0 fi ,4-
Z (please print)
W
Signature Title GtMli-FdL
(over)
DOH-1555(02/2004)