Scott, James E 09/111201 00:49 131535.32589 PAGE 01/04
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NEW YORK STATE DEPARTMENT OF H EALTH Buriat-Transit Permit
Bureau of Vital Records
Sex
Name First Middle last1 Male
James E.Scott __ — —1 --
Date of Death Age If Veteran of U.S.Armed Forces,
12/11/2022 57 Years War or Dates �--.—
____— _
N Place of Death hospital,Institution of
City,Town or Village Moreau Town , Street Address 540 eansevoort Road A,Moreau Town,N6W York 12828
Undetermined ❑Pe York
Manner of Death ❑Natural Cause Accident Fbmicide ❑Suicide _
— � — ❑ ❑ ----1Crcumsta,ces Investigation
C Medical Certifier Name Tice —
o Shannon Evelliis PA
Address
9 Carey Road,Queensbury Town,New York 12904 --
—
Death Certificate Filed Dirlct Number Register Number
Town�f Moreau � 4562 ( 64
C ,Town orVilla a --
Burial Date Cemetery,Crematory or Facility Name
12114rao22 FineviBw Crematory
i--,
Entombment Address J
Cremation QueenDury Hamlet,New York
pDonation _
g[]Removal Date Place Removed —
andior _ and/or Weld
� Hold Address
I
pate
5 by Common TPointofgr:]Transportation ,lShipment —
Carrier Destination
_--
Date j Cemetery Address
Disinterment I Dale Cemetery Address
❑Reinterment _ _
Permit Issued 10 — Registration Number
Name of Funeral Home Bunk Funeral Hone Inc —_ 00238
Address
7 Park St,Norwood,New York 13668 —_--__
Nance of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,if Other than Above —
Address
IC
Permiaaion is hereby granted to dispose at the human remains described above as indicated.
Date Issued 12/14/2022 Registrar of Y tat Statistics —Lamm gic'ecr6e/E'leacrimi agi'4110dJ
�. (sf rw(uel
District Number 4562 Piece Town Or Moreau
— —
I certify that the remains of the decedent identified above were disposed of in accordance with this prrmitam
F ^
W Date of Disposition /2//_-1c'2�Place of Disposition �i. G,r e,.,c) > &�!'
NE
ILI
di /sealant (7otRau 1 armnumtberl`—
Name of Sexton or Person in Charge rem' / -- '`il 1/1 °-P i
Z
W Signature —._ Title _ ._J-'ed — -- ---
D0H•1555(07/18)p f of 2
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#