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Spath, Leon R. NEW YORK STATE DEPARTMENT OF HEALTH OLFBureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Leon R.Spath Male Date of Death Age If Veteran of U.S.Armed Forces, 11/10/2019 78 Years War or Dates 1964-1966 I— Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town —7Street Address 1169 Ridge Road,Queensbury Town, New York 12804 `Q Mannerof Death " Natural Cause Accident Homicide Suicide Undetermined Pending V Circumstances Investigation W Medical Certifier Name Title Shannon Evelis PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 164 ©Burial Date Cemetery,Crematory or Facility Name 11/15/2019 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York ❑Donation z ❑Removal Date Place Removed and/or and/or Held F- Hold Address N O IL Date Point of t) ❑Transportation S by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address tu CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2019 Registrar of Vital Statistics Camlfne7f�garkOar6er(!Yectmnica-5Signe�J (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition 1 1 1 1 51 2 01 9 Place of Disposition ilakQr Rd a 2 4 0 (a dress) 4 W S. I. N (sedan) (lot number) (grave number/ O Name of Sextoppr Person in Cha a of Premis Connie L. Goedert (Please print)Z W Signature r` Q Title Superintendent i DO H-1555(07/18)p 1 of 2 S � Public Health Law Sec. 4145(2b) 010352 Receipt Human remains of `-` w . delivered on Pine"iew Cemetery Repre ting the funeral home named on burial permit Official Funeral Directors Reg.or License# '� } SPATH NAME Leon R. Spath Age: 78 Lot Owner:Leon R. Spath Lot#S. I. 40 Grave# 4 Case: Concrete Died: Interred: 11 /10/2019 11 /15/2019 Funeral Home: Maynard D. Baker Funeral HOme Cemetery:Pine View r E,