Seaver Jr., LeGrand I
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
,r. Name First Middle Last Sex
LeGrand Seaver,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2017 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Indian River Nursing Home
Manner of Death X Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Kandora Dr.
Address
,F.+ 318 Broadway,Fort Edward,NY 12828
ii:{f Death Certificate Filed District Number Register Number
i City, Town or Village (7r n t'/(ii) ` 7A3
®Burial Date Cemetery or Crematory
February 18, 2017 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
as by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
f_: Permit Issued to Registration Number
r,'N Name of Funeral Home Regan Denny Stafford Funeral Home 00694
Address
11l{� 1867 State Street, Schenectady, NY 12304
x�.
NI Name of Funeral Firm Making Disposition or to Whom
,f Remains are Shipped, If Other than Above
Address
., Permission is here y granted to dispose of the human re ins descr' d ab as indicated.
N Date Issued �7 /� Registrar of Vital Statistics ' C.. A,e)-`-�
(signature)
'A? District Number 6 jai 5- Place 6je 4>at /1/f
f— I certify that the remains of the decedent identified above wee disposed of in accordance with this permit on:
W Date of Disposition 2/1 8/1 7 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W
CO Unadilla Ext. 14A 1
W (section) (lot number) (grave number)
Z Name of Sex,•n or Person in Charge of Premises Connie L_ Goedert
_ (please print)
W Signatur / , , ,a_cJA4-1 Title Cemetery Superintendent
(over)
DOH-1555(02/2004)