Richards, Leon . NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leon Robert Richards Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 13, 2016 77 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of DeathLai Natural Cause Accident El Homicide Ei Suicide riUndetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Stephen Perazzelli, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
}i r, Town or Village (,�/en S {,t //i ,-6cj i 2
®Burial Date Cemetery or Crematory
0.5/R-V o14 Scotch Cemetery
❑Entombment Address
0 Cremation /l Rd. Q./caNS,�k.�r, �y 1 4f
Date J dace Removed
z El Removal and/or Held
and/or Address
17. Hold Scotch Cemetery
CD Date Point of
0 ElTransportation Shipment
CO by Common Destination
Et Carrier
ri
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
C
W
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued - ii r/14 Registrar of Vital Statistics l i G �j�c r,
(signature)
District Number S -7 41 Place /0 cv pi G "F Ik % n f S 6 vey
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
Z
W Date of Disposition 5/27/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W Scotch 5
W (section) (lot number) (grave number)
O Connie L. Goedert
O Name of Sext or Person in Charge of Premi
(please print)
W+ Signature ita-ze- ce—P Title Cemetery Superintendent
i
(over)
DOH-1555 (02/2004)