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Skellie, Scott Preston NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Scott Preston Skellie Male Date of Death Age If Veteran of U.S.Armed Forces, 05/09/2021 53 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing pManner of Death ©Natural Cause El Accident Homicide El Suicide ❑Undetermined Pending W Circumstances Investigation WMedical Certifier Name Title CI Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 40 ElBurial Date Cemetery,Crematory or Facility Name 05/11/2021 Pine View Crematorium ElEntombment Address X❑Cremation Queensbury Town,New York ElDonation Z❑Removal Date Place Removed and/or and/or Held Hold Address CO 0 el- Date Point of U) Li Transportation Shipment p by Common Carrier Destination Date Cemetery Address Disinterment 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 ▪ Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/11/2021 Registrar of Vital Statistics Jenny Linda 94 ilartel(e(E(ectronicalTySigned) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition S I t3111 Place of Disposition 2 (address) W CC CC (section) / (lot number) (grave number) O G L ▪ Name of Sexton or Person in Charge of Pre es Z (p/ase print) W Signature Title �'r" `R rate DOH-1555(07/18)p 1 of 2 1�. Public Health Law Sec. 4145(2b) it783 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named orb burnal permit Official Funeral Directors Reg.or License#