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Dobert, Scott Edward -_ # (07C NEW YORKSTATE DEPARTMENTOF HEALTH 4.61- s Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Scott Edward Dobert Male Date of Death Age If Veteran of US.Armed Forces, 08/21/2023 63 Years War or Dates i_ Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 104 Coolidge Avenue,Queensbury Town,New York 12804 p Manner of Death ❑X Natural Cause Accident ❑Homicide 0Suicide Undetermined ElPending W Circumstances Investigation W Medical Certifier Name Title David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number Cit ,Town or Village 5657 129 Burial Date Cemetery,Crematory or Facility Name 08/23/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 O. Date Point of U)❑Transportation Shipment p by Common Carrier Destination O 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 l` Remains are Shipped,If Other than Above Address CC 11J IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/23/2023 Registrar of Vital Statistics Caroline 7fififegarde Barber(E(ectronica((y Signed) (signature/ District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition g/Zi(ID Place of Disposition -�t..V 2 (address) W CC (sealant r (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises h L It b- Z (pi print) W Signature L�� Title DOH-1555(07/18)p 1 of 2 r, ! ' 4Public Health Law Sec. 4145(2b) Receipt Human remains of .r delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#