Leeret, Mary it Goo
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section to Burial - Transit Permit
Name First Middle Last Sex
Mary Barbara Leeret Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/04/2011 70 years War or Dates
j- Place of Death Hospital, Institution or
6 City, Terljt Saratoga Borings Street Address Wesley Health Care Center
▪ Manner of Death LI Natural Cause D Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Matthew C Pender M D
Address
35 Gilbert Street, Cambridge, N Y 12816
Death Certificate Filed District Number Register Number
City, Txxxgr) Ij�g Saratoga Springs 4501 511
❑Burial Date Cemetery or Crematory
"'Entombment Pineview Crematorium
Address
G]Cremation Queensbury N Y
Date Place Removed
Removal and/or Held
p❑aHoldor Address
nd/
i
0. Date Point of
ai ❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 0048
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,' Address
tilt
fl' Permission is hereby granted to dispose of the human remai rib d aboveas indicated.
Date Issued 12/06/2011 Registrar of Vital Statistics Ure -4-"Utzthu_ft
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
tLf Date of Disposition iut.
NI Place of Disposition 20,4V IN t rttwito(iUl.
2 (address)
U,
CC (section) (lot n+umber). n (grave number)
aName of Sexton or Perso in Charge of remises ibt+Y\ N{ ht'(f1
l (pl Ee print)
la
Signature k� Title C 11arOL
(over)
DOH-1555 (02/2004)