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Burda Jr., Leo NEW YORK STATE DEPARTMENT OF HEALTH 1 Vital Records Section Burial - Transit Permi Name First Middle Last Sex Leo J.Burda Jr. Male 4 Date of Death Age If Veteran of U.S. Armed Forces, x 04/27/2018 70 Years War or Dates ttit Place of Death Hospital, Institution or City, Town Or Village Glens Falls Street Address Glens Fails Hospital q`' Manner of Death©Natural Cause 0 Accident Homicide Suicide Undetermined �Pending ; i Circumstances Investigation 1 Medical Certifier Name Title - Stephen Perazzelli MD Address 4 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 213 ❑Burial Date Cemetery or Crematory 04/30/2018 Pineview Crematorium ❑Entombment Address ? ',®Cremation Queensbury Town, New York : Date Place Removed a ❑Removal and/or Held and/or Address Hold Date Point of Q Transportation Shipment -, by Common Destination Carrier Q Disinterment Date Cemetery Address - Q Renterment Date Cemetery Address Permit Issued to Registration Number 4., Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 v Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/30/2018 Registrar of Vital Statistics cg6ertA Curtis(Electron ca(IySigned) ,i., (signature) 441 District Number 5601 Place Glens Falls, New York lA I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: : Date of Disposition 113b f I( Place of Disposition fold (-1..,, (address) (section) lot number (grave number) 1` Name of Sexton or Person in Charge of Premises r•. L (pl se pn Signature h Title 0101,i111, (over) DOH-1555(02/2004)