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VanNess, Leo NEW YORK STATE DEPARTMENT OF HEALTH 'It no Vital Records Section ''' � Burial - Transit Permit Name First Middle Last Sex Leo Francis VanNess Male Date of Death Age if Veteran of U.S. Armed Forces, October 24, 2018 58 War or Dates 4. Place of Death Hospital, Institution or W City, Town or Village Fort Edward Street Address 104 McUntyre Street W Manner of Death J Natural Cause Accident El Homicide El Suicide El Undetermined ri Pending Circumstances Investigation W' Medical Certifier Name Title L� Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Numb Register Number� _ City, Town or Village ❑Burial Date Cemetery or Crematory October 26, 2018 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ni Removal and/or Held and/or Address F. Hold O' Date Point of 0. 0 Transportation Shipment (0 by Common Destination 1; Carrier ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above c Address W O. Permission is he eby ranted to dispose of the human re desc ibed boye/as Ind' ated. Date Issued 0 Q/C'p 0 g Registrar of Vital Statistics a Y . „_____-- ( 'gnature) 4 District Number(5'166 Place ) 610 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ili Date of Disposition 10/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804 W' (address) W (section) (fit number) (grave number) 4 a 0 Name of Sexton or Person in Charge of Premises 1 ti er Sa►�4is (plea pent) W Signature Title Mom +ut (over) DOH-1555 (02/2004)