LeBlanc, Richard Robert NEWYORK STATE DEPARTMENT OF HEALTH 7 �
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last 7M%1
Richard Robert LeBlanc
Date of Death Age If Veteran of U.S.Armed Forces,
03/10/2020 78 Years War or Dates 61-64
�,. Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death �Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Wendy Steinhacker PA
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 42
Burial Date Cemetery,Crematory or Facility Name
03/13/2020 Pine View Crematory
Entombment Address
aCremation Queensbury,New York
❑Donation
Z Removal Date Place Removed
O and/or and/or Held
~as Hold Address
O
IL Date Point of
Transportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
jo Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f. Remains are Shipped,If Other than Above
Z Address
Q
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2020 Registrar of Vital Statistics CaroCtnexlJegar�Bar6er�ElectronicaldySrgnedJ
(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:
W Date of Disposition 3 1311 Place of Disposition fv
(address/
W
(section) (lottnumber/ (� l (grave number)
Name of Sexton or Person in Charge f Premises
(p
2 se print/
W Signature 161 Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01311 3 0
Receipt
Human remains of delivered on ` , 20
..-,Tine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#,.