Mann, LeLand A. /1 �o
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last FMS
ex
Leland A Mann ale
Date of Death Age If Veteran of U.S.Armed Forces,
05/11/2020 80 Years War or Dates 1959-1963
II.- Place of Death Hospital,Institution or
WCity,Town or Village Corinth Town Street Address 41 Fuller Road,Corinth Town,New York 12822
p Manner of Death 0 Natural Cause Accident Homicide ❑Suicide Undetermined Pending
LL1 Circumstances Investigation
U
W Medical Certifier Name Title
Susan Dorsey MD
Address
1 West Avenue,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Corinth 4553 15
Burial Date 7Cemetery,Crematory or Facility Name
05/13/2020 view Crematory
Entombment Address
RI Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
F- Hold Address
O
C- Date Point of
U) ❑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 100448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
2 Address
lY
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/12/2020 Registrar of Vital Statistics Rose E Farr(Electronically Signed)
/signature/
District Number 4553 Place Corinth, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition ��3�1/j2t'J Place of Disposition
Uj (address)
lu
U)
(section) tlot number) (grave number/
aName of Sexton or Person' Ch e of PremisesQ-
Z (please print)
W Signature Title G ��t
DOH-1555(07/18)p t of
1
Public Health Law Sec. 4145(2b) 013800
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#