Leary, Christopher4-)i o
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
Christopher Leary
I Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/26/2019
67 Years
War or Dates
F
Place of Death Hospital, Institution or
Z
City, Town or Village Johnsburg Town Street Address Elderwood at North Creek
W
�
Manner of Death Undetermined Pending
❑X Natural Cause � Accident � Homicide � Suicide � � g
W
Circumstances Investigation
W
Medical Certifier Name Title
G
Michael Miles MD
Address
112 Ski Bowl Rd, Johnsburg Town, New York 12853
Death Certificate Filed
District Number
Register Number
City, Town or Village North Creek
5655
43
Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/29/2019 Pine View Crematory
Address
RI Cremation
Queensbury Town, New York
Donation
Z
Removal
Date
Place Removed
and/or
and/or Held
H
Hoid
Address
N
O
�.
Date
Point of
N
p
Transportation
by Common
Shipment
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Alexander Baker Funeral Home
00037
Address
3809 Main St, Warrensburg, New York 12885
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 10/28/2019 Registrar of Vital Statistics Kathleen C Coralr (EkctronwaiiySoned)
(signature)
District Number 5655 Place North Creek, 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 ID 1761 ) Irj Place of Disposition ,
W
(address/
W
N
(section) (iot number. (gravenumber)
Name of Sexton or Person in Charge of Premises �' �"' k,.#&
(p ase prATT
W
Signature Title c-m ASt
�P Z
DOH-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b) - -
0, 3035
Receipt
Human remains of w�� ,f delivered on
i
Pine View Cemetery
Official
,20 _
Representing the funeralTiotrie named on burial Vern -fit
Funeral Directors Reg. or License # -