Scoville, Sheina Elllen A ;"(
N EW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Sheina Ellen Scoville Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/18/2021 40 Years War or Dates
E., Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 28 Crandall Street,Glens Falls,New York 12801
• Manner of Death ❑X Natural Cause ❑Accident Ei Homicide ❑Suicide ❑ Undetermined Pending
W U Circumstances Investigation
WL1 Medical Certifier Name Title
Vincent Meyer MD
Address
418 Geyser Road 14,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 255
▪Burial Date Cemetery,Crematory or Facility Name
06/23/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
~ Hold Address
0
U) 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 Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/22/2021 Registrar of Vital Statistics Rp6enf7ndrewCurtzrgkctronica*Signea)
(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:
IH
Z Date of Disposition t joty`�pa f,I Place of Disposition „,t, V�,t, Ci! 9I,(Y
1 (address)
W
to
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Tt frut y 5 ;r1J-S
Z (please print)
W Signature ,,,,)01/e(00Title 410
DOH-1555(07/18)p 1 of 2
.f #r
Public Health Law Sec. 4145(2b) ; K-
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit yl
Official Funeral Directors Reg.or License# `'•