Siwek, LeonardCOPY OFY IS PERMIT MUST
PERMIT NUMBER
ACCOMPANA T E BODY TO THE STATE OF ARIZONA
FINAL DESTINATION. DEPARTMENT OF HEALTH SERVICES - BUREAU OF VITAL RECORDS
DISPOSITION TRANSIT PERMIT
AL
1. DECEDENTS LEGNAME (FIRST, MIDDLE, LAST, SUFFIX) 2. SEX 3. DATE OF BIRTH
D4. q OFF DEATH —
IDENTIFICATION
IDENTIFICATION LEONARD, ALBERT, SIWEK MALE 06/30/1929
09/11/2019
OF DECEASED 5. PLACE OF DEATH - CITY OR TOWN S. COUNTY
7. STATE
PHOENIX MARICOPA
ARIZONA
8. NAME AND ADDRESS OF FUNERAL FACILITY OR PERSON RESPONSIBLE
HANSEN MORTUARY
8314 N 7TH STREET, PHOENIX, AZ 85020
9. NAME OF FUNERAL DIRECTOR OR RESPONSIBLE PERSON
MANNER AND PLACE BRADLEY, J., HANSEN
OF DISPOSITION 10. METHOD OF DISPOSITION 11. NAME AND LOCATION OF 1 DISPOSITION FACILITY
12. DATE OF DISPOSITION
PINEVIEW CEMETERY,
REMOVAUBURIAL QUEENSBURY, NY, US
09/13/2019
13. METHOD OF DISPOSITION 14. NAME AND LOCATION OF 2 DISPOSITION FACILITY
IS. DATE OF DISPOSITION
AUTHORIZATION
16. MEDICAL EXAMINER'S AUTHORIZATION FOR CREMATION
17. DATE OF AUTHORIZATION
A.A.C. R9-19-313 REQUIRES THAT A PERSON IN CHARGE OF A PLACE OF FINAL DISPOSITION IN ARIZONA SHALL MAINTAIN A COPY OF THIS DISPOSITION TRANSIT PERMIT AT THE PLACE OF FINAL DISPOSITION FOR AT LEAST FIVE YEARS AFTER THE ISSUE DATE
VS-8 Rev. 7/2017
Public Health Law Sec. 4145(2b)
010346
Receipt
Human remains of e v t,)i/) ') ';"
delivered on —,20
A
Pig View Cemetery ie*esengng the 6eral home named oj?u�-o permit
Official FAfieral Directors Reg. or License # /, / —