Williams, Leon NEW YORK STATE DEPARTMENT O 4 )0
Vital Records Section Burial - Transit Permit
Name First Last Sex
Leon Williams Male
Date of Death A If Veteran of U.S. Armed Forces,
September 11, 2015 68 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident n micide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
1-4 John P. Stoutenberg, M.D. Dr.
Address
102 Park Street GI , N 280
Death Certificate Filed District Number_, Regist er
City, Town or Village Glens Falls O0`
ID Burial Date tery or Crematory
September 14, 2015 Pine View Crematory
0 Entombment Address
en®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
�, and/or Address
Hold
Date Point of
❑Transportation Shipment
_ by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
- El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
kRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
=_-;- Date Issued 9 I f L-i j IS Registrar of Vital Statistics LC k,J
(sign tune)
District Number O/ Place G (cLA AS V�S " Y r
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) C (grave number)
Name of Sexton or Pers in Charg f Premisesi�,� �...�^ SO.•n!�}
/ ��'O (pfaase print)
Signature G �� Title nIC� stt
9
(over)
DOH-1555 (02/2004)