Hermance, LeRoy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LeRoy F. Hermance Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 17,2011 82 War or Dates World War II
.. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Wp Manner of Death I XI Natural Cause Accident { 1 Homicide Suicide Undetermined Pending
Ut Circumstances Investigation
w Medical Certifier Name Title
0 Michael Varughese,MD
Address
Glens Falls Hospital,New York
Death Certificate Filed Dist ' I u Regist ��r
City, Town or Village Glens Falls � j
❑Burial Date Cemetery�orr Crematory
March 21, 2011 j Pine View Crematorium
❑Entombment Address
rii Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
H Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
2 Address
IY
W
0 Permission is hereby ranted to dispose of the human remains descr' ed a v s i i d.
,
Date Issued 03 2/ Z_// Registrar of Vital Statistics
(signature)
District Number '0/ Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3"Z�(- If Place of Disposition `A (A.e%.„) C,re,-►ic_ °('.v m
2 (address)
W
CO
0 „Luteti um) ift(lo-t number) (grave number)
ap Name of Sexton or Per on in Charge of remises h 1 rv►o`�./ vvvejK
W
(please print) _�))
Signature`— Title Cr vil a4-dty r45.5`t •
(over)
DOH-1555(02/2004)