Spaulding, John Scott 1(15
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Scott Spaulding Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/03/2021 91 Years War or Dates 1949-1951
Place of Death Hospital,Institution or
Z City,Town or Village Milton Town Street Address 827 Ediface Way,Milton Town,New York 12020
Manner of Death 0 Natural Cause ❑Accident 1=1Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
U
0 Medical Certifier Name Title
James Gaylord MD
Address
1184 50 Route,Ballston Lake Hamlet,New York 12019
Death Certificate Filed District Number Register Number
City,Town or Village Ballston Spa 4561 13
0 Burial Date Cemetery,Crematory or Facility Name
02/05/2021 Pine View Crematory
❑Entombment Address
aCremation Queensbury Town,New York
❑Donation
cRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
0_ Date Point of
U) ❑Transportation
0 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/05/2021 Registrar of Vital Statistics Brenda7fowe('Yectronicaf Stgne,c0
(signature)
District Number 4561 Place Ballston Spa, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /42,
Z Date of Disposition 2 Ti Place of Disposition 4'L
2 (address)
W
U)
CC (section) (lo umber) (grave number)
Name of Sexton or Person in Charge of Premises
Z (please pit)
W Signature l2� �� Title rewirki
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 1 7 08
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#