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Leavitt, David J. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David J.Leavitt Male Date of Death Age If Veteran of U.S.Armed Forces, 05/12/2020 88 Years War or Dates 1951-53 Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 91 Main St, Hudson Falls Village, New York 12839 p Mannerof Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation tU11 Medical Certifier Name Title Kenneth France MD Address ' 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 12 ❑Burial Date Cemetery,Crematory or Facility Name ❑ 05/14/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held bi N Hold Address O CL N ❑Transportation Date Point of p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Re ration Number gist Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom �•+ Remains are Shipped,If Other than Above Address IX W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/13/2020 Registrar of Vital Statistics Cynthia ABardin(ECectronicallySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- W Date of Disposition -��/-Z02_0 Place of Disposition �1'lL ,� er f (address) (section) (!o umber/ (grave number) Name of Sexton or Person i arge Premises !"'1 i Z44'w 4&4� Z //please print/ W Gr, Signature Title �P�n c r DO H-1555(07/18)p 1 of Public Health Law Sec. 4145(2b) . 13 8 1 F Receipt Human remains of delivered on , 20 j Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#