LeClair, Edward T. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edward T LeClair Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/16/2020 90 Years War or Dates 1946-1953
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
Jean Flanagan MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 179
Burial IDate Cemetery,Crematory or Facility Name
04/18/2020 Pineview Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
d Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W --
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/17/2020 Registrar of Vital Statistics W2o&#,gnrdrewCnrtzr(,-kctronicab Syned�
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F— L,
Date of Disposition '7—2.0•Z02y Place of Disposition L ,� d L/t.r✓tc.��'�
W (address/
W
N (section) (lot number) (grave number)
IIr _
Name of Sexton or Perso Ch a of remises �l"'�' �'H c,-j" L
(please print)
W Signature Title G
DOH-1555(07/18)p 1 of 2
. r
Public Health Law Sec. 4145(2b) 013,9 6 t
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#