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Rymkewicz, Leslie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Leslie J. Rymkewicz male Date of Death Age If Veteran of U.S. Armed Forces, December 4, 1997 80 War or Dates no 1 Place of Death Hospital, Institution or City, Town or Village Town of Queensbury Street Address 5 Greenway North Manner of Death©Natural Cause 0 Accident 0 Homicide ❑Suicide El Undetermined. Pending Circumstances Investigation iii Medical Certifier Name Title I Bernardo Villajuan MD Address iiie 90 South St. Glens Falls, NY 12801 : Death Certificate Filed District Number Register Number City, Town or Village Town of Queensbury -1-)2.ti7 /3.- Date Cemetery or Crematory ©Burial Dec. 8, 1997 Pine View Cemetery Address ❑Cremation Queensbury, NY Date Place Removed 0❑Removal and/or Held and/oriiTi Address 0 Hold . Date Point of V?❑Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address Reinterment Date Cemetery Address iI:si P:iiiiiiiermit Issued to Regisiiia�i Number miiiName of Funeral Home Regan and Denny Funeral Home U15b� n' Address 53 Quaker Road, Queensbury, NY 12804 iLiii • Name of Funeral Firm Making Disposition or to Whom 0 Remains are Shipped, If Other than Above gioll Address li . iiil Permission is hereby granted to dispose of the human rem s described above 'ndicated. lie Date Issued (1.-S'-R 1 Registrar of Vital Statistics /` )0.,e (signature) _____ iiiiiiiiiDistrict Number S"j Place_ ..-t.�Q2,_., ,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F iii Date of Disposition 12/8/97 Place of Disposition Pine View Cemetery,Queensbury,NY 2 (address) la u) Mohican 8 6-R 1 li (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises Rodney G. Mosher Z (please print) Signature ezQ ,,,_4)4 r;-171 Title Superintendent DOH-1555 (10/89) p. 1 of 2 VS-61