Every, Leonard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
F.. Name First Middle Last Sex
Leonard Every 1 Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 1,2012 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
:n; Manner of Death l Xl Natural Cause n Accident 0 Homicide Suicide Undetermined Pending
•,ti Circumstances Investigation
y ; Medical Certifier Name Title
�' Mathew Varughese,MD
Address
. Glens Falls NY
•x' Death Certificate Filed District Number I Register Number
City, Town or Village Glens Falls,NY 5601 1 i
LX Burial Date Cemetery or Crematory
Entombment January 3,2012 Shaaray Tefila
Address
❑Cremation Media Drive, Queensbury,NY 12804
Date Place Removed
an Removal and/or Held
and/or Address
P Hold
tl1
O Date Point of
co Li Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
�'ti'ti Permit Issued to Registration Number'� Name of Funeral Home Singleton-Healy Funeral Home 01596
• Address
407 Bay Road,Queensbury,NY 12804 _
Name of Funeral Firm Making Disposition or to Whom IRemains are Shipped, If Other than Above
Address
% Permission is hereby granted to dispose of the human remains described above as indicated.
ti { Date Issued 1 ) 3'/ / Z Registrar of Vital Statistics wC- -ti'�
..• (signature)
District Number 36 0 i Place 6 i - S Vck \\.s / of y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition Place of Disposition
M (address)
CO
IZ (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
,Z (please print)
W Signature Title
(over)
DOH-1555(02/2004)