LeClaire, Nancy NEW YORK STATE DEPARTMENT OF HEALTH t `.---
Vital Records Section f - - 1 Burial - Transit Permit
—
Name First Middle Last Sex
Nancy C. LeClaire Male
Date of Death Age If Veteran of U.S.Armed Forces,
I' April 2, 2011 74 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Queensbury Street Address Residence
O Manner of Death 0 Natural Cause Ej Accident El Homicide 0Suicide 0 Undetermined El Pending
w Circumstances Investigation
u Medical Certifier Name Title
iii Dr. Darci Ann Giaotti-Grubbs, M.D.MD
0 Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Numb r Register Number
City,Town or Village Queensbury c- 9 a --)
El Burial Date Cemetery or Crematory
04/06/2011 Pineview Crematorium
0 Entombment Address
ElCremation Queensbury, NY 12804
2 Date Place Removed
0 0 Removal and/or Held
• and/or Address
f' Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
. Date Cemetery Address
a0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
I_-
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I I Registrar of Vital Statistics ��� D
(signature)
District Number c(0 S'--) Place Queensbury,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tuDate of Disposition �f-L-ij Place of Disposition Pineview Crematorium
2 (address)
0 (section) /� (lot number)` (grave number)
g Lhs} Iv J
? Name of Sexton or P�son in Char a of P mises t. ,n � •h�„��+-
W / )(please print)
Signature C J, Title CKE1f 1q f o jL
(over)
DOH-1555 (02/2004)