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Scott, Richard A. ISI NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard A Scott Male Date of Death Age If Veteran of U.S.Armed Forces, 02/06/2021 70 Years War or Dates F_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 0 Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title G Marvin Davidowitz MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number Gty,Town or Village Glens Falls 5601 83 ElBurial Date Cemetery,Crematory or Facility Name 02/08/2021 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation goRemoval Date Place Removed and/or and/or Held H Hold Address O O. LI Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Q W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2021 Registrar of Vital Statistics Wcibert Andrew Curtis(ECectronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition Zito)Z+ Place of Disposition (ad ress) W CC (section) (lot mbgr) (grave number) SName of Sexton or Person in Charge of Prem. s 1 Pi. ti44 (please prin W Signature Title ` ^0 a DOH-1555(07/18)p 1 of 2 1 Public Health Law Sec. 4145(2b) 5'" f' Receipt I Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '