Leahon, Peter it
NEW YORK STATE DEPARTMENT OF HEALTH z zc
Vital Records Section Burial - Transit Permit �\
-. Name First Middle Last Sex
Peter J. Leahon Male
: Date of Death Age If Veteran of U.S. Armed Forces,
3= April 25, 2012 70 War or Dates Vietnam
�, Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address ` . "l L, ,),-,q ..) ,_ '1
0; Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
11.1 Circumstances Investigation
Ail
Medical Certifier Name Title
Gary Scidmore,Coroner
Address
cu' 1340 State Rt.9 Lake George,NY 12845
+ Death Certificate Filed District Number / 1 Register Number i
; City, Town or Village Lake George Go 1 CJ
❑Burial Date Cemetery or Crematory
May 1, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
u) I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
} ; Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
': 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
Address
:ice..
Ili
Permission is hereby granted to dispose of the human rem ins described above a indicated.�
Date Issued 5 li 0/�., Registrar of Vital Statistics t). Lt 4,7. 1�,.
! (signa ure)
'‘ District Number 5 be 0 Place Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �I
W Date of Disposition S./i 111. Place of Disposition i,�,t/Vuta t tart,4__
2 (address)
W
U)
O (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of P, mises A r�1 ,� Je4.4
Z � � (please print)
w A L Title arc',tyncytOvt-
Signature
(over)
DOH-1555(02/2004)