Delong, Scott K ,N3e/iq
,..4,f)--
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Scott K.DeLong Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/26/2022 63 Years War or Dates
1... Place of Death Hospital,Institution or
LLJ
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Homicide Suicide El Natural Cause Accident Undetermined ❑Pending
LIJ
0 Circumstances Investigation
CI
Medical Certifier Name Title
Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 287
Burial Date Cemetery,Crematory or Facility Name
1` 04/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
1.. and/or and/or Held
N Hold Address
0
O. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
N Address
2
W
Cl. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(s)gnature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH ;�
Z Date of Disposition 93er-2a'Z Place of Disposition /�c ,,JP 1,,,`.„u) r
LIJ
2 add es
W
CO
O (section) ��,,,, (lot nu b� (grave number)
Name of Sexton or Person in Char f Premise 4l/47O�/�
Z please print)
W SignatureCr," 1' Title v }—c r
DOH-1555(07/18)p 1 of 2
Q � ? � yy
1, �
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#