Sipowicz Jr., Lenard NEW YORK STATE DEPARTMENT OF HEALTH .fl S
Vital Records Section Burial - Transit Permit
Name First iddle -- Last Sex
4,' Lenard Jo •h Sipowicz Jr. Male
Date of Death Age If Vetera of U.S. Armed Forces,
May 5, 2018 52 War Dates
• Place of Death Hospital, Institution or
' ` City, Town or Village South Glens Falls treet Address 41 Hudson Avenue
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0 Manner of Death❑Natural Cause ❑ Accident D Homicide Q Suicide ❑ Undetermined El Pending
{iiCircumstances Investigation
Medical Certifier Name Title
I
Address
40 Death Certificate Filed District Number Register Number
City, Town or Village
. 1.❑Burial Date Cemetery or Crematory
- May 8, 2018 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z, ❑ Removal and/or Held
• and/or Address
Hold
Date Point of
4911
it ❑Transportation Shipment
O by Common Destination
▪ Carrier
Disinterment Date Cemetery Address
Reinterment.4 17.1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
IAddress
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
Address
L0
1:0-
Permission is h reb granted to dispose of the human rema' s described above as indicated.
' Date Issued 5 g / Registrar of Vital Statistics .
(signature)
District Number L + / I
!�J��l7 Place Y / liQ.9P � �U�fh Cr Cyr S' f--• u-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 05/08/2018 Place of Disposition Quaker Road Queensbury,NY 12804
,a_ (address)
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Et (section) /(lot number) (grave number)
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1
Name of Sexton or Person in Charge of Premises ^^•� 5�++�
(pkase print)
Signature Title alllel0 coN,
(over)
DOH-1555 (02/2004)