Wood, Leslie NEW YORK STATE DEPARTMENT OF HEALTH t - $ O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leslie H. Wood Male
444, Date of Death Age If Veteran of U.S. Armed Forces,
November 5, 2017 99 War or Dates World War II
; Place of Death Hospital, Institution or
, Town or Village
W!I-- Ci ty 9 i tis e, I Street Address 1112 Vaughn Road
WbManner of Death X❑Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
dical Certifier tl Name , h Title
Trk
Address I L0 C-E Rotarb 0J� /.1 S� � \i
Death Certificate Filed " District Number Register Number
City, Town or Village s'y(�j 18
,❑Burial Date Cemetery or Crematory
November 7, 2017 Pine View Crematorium
❑Entombment Address
t®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or
Hold Address
j.. Pine View Cemetery
Date Point of
`❑Transportation Shipment
0 by Common Destination
1;1 Carrier
ri
❑ Disinterment 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
Address
t
a. Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued j is 17.aQ 12 Registrar of Vital Statistics e r, C_e_)..Qpi_u--o.-.e
District Number 76 a Place ` �-c.a.r.- _ T' se a r
\ c Gf
I certify that the remains of the decedent identified abov�were disposed of in acco dance with this permit on:
w Date of Disposition 11/07/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W Pine View
reW �n Zti��1jxt lu lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises �s se Sr^�err
Z
(ple print)
LP Signature Title L"('6�t++Jt ►1-?�--
(over)
DOH-1555 (02/2004)