Leach, Gilbert�
NEW YORK STATE DEPARTMENT OF HEALTH �gi
Burial -Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
I
Gilbert Bruce Leach
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/20/2019
88 Years
War or Dates 1951-1955
Place of Death
Hospital, Institution or
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City, Town or Village Glens Falls
Street Address The Pines At Glens Falls Center For Nursing & Rehabilitation
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Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
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Circumstances Investigation
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Medical Certifier Name Title
Gwendolyn Morris -Dickinson PA
Address
170 Warren St, Glens Falls, New York 12801
Death Certificate Filed
District Number
Register Number
City, Town or Village Glens Falls
5601
460
❑ Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/22/2019 Pine View Crematory
Address
91 Cremation
Queensbury, New York
Donation
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Removal
Date
—7and/or
Place Removed
and/or
Held
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Hold
Address
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O
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Date
Point of
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Transportation
by Common
Shipment
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Maynard D Baker Funeral Home
01130
Address
11 Lafayette St, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/22/2019 Registrar of Vital Statistics WpAwA77dnewCurt&�Z-&-tromi7allySo-ed�
(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:
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Date of Disposition 10I 23115 Place of Disposition 0,4 1w4v fsrL;
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(address)
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N
(section) (lot nu mbe (grave number)
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Name of Sexton or Person in Charge of Premises n I
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Signature Title
DOH-i555 (07/18) p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of
Pine View Cemetery
Official
delivered on ; � , 20
Representing the fun&Al home- named on burial permit
Funeral Directors Reg. or License # r