Hogan, Leonard -1)
NEW YORK STATE DEPARTMENT OF HEALTil l 3 # 1-1 Vital Records Section Burial - Transit Permit
-' Name First Middle Last Sex
Leonard Peter Hogan Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 15, 2012 78 War or Dates
Place of Death Hospital, Institution or
Ci
W ty, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death 0 Natural Cause 0 Accident 0 Homicide El Suicide nUndetermined El Pending
LU
Circumstances Investigation
ill; Medical Certifier Name Title
CI Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad St. Plaza Glens Falls, NY 12801
,, Death Certificate Filed District Num Regi ber
City, Town or Village .e1
❑Burial Date Cemetery or Crematory
September 17, 2012 Pine View Crematorium
❑Entombment Address
[XJCremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
E Hold
CD Date Point of
cEl Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
_' Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
t; Remains are Shipped, If Other than Above
Address
Ui
CL Permission is hereby granted to dispose of the human remains de ib ve 1 •icated.
Date Issued 9 /7`Zo/2.- Registrar of Vital Statistics ,L11�
(signature)
District Number AO/ Place Cl�l � G/�, ,L> 14'�1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
M i�
Z` Date of Disposition p
p j-i�-it Place of Disposition PwV iff,L4"yL..,
M (address)
Uf
C (section) (lot numbe (grave number)
f Name of Sexton or P rson in Charge f Premises t'- "'`'
bi-
zI
i�] (please print)
tLC Signature Title CMet IA—
(over)
DOH-1555 (02/2004)