French, Leona NEW YORK STATE DEPARTMENT OF HEALTH 4i- Ll t l
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leona D. French Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 12,2012 92 War or Dates
,'v. Place of Death Hospital, Institution or
City, Town or Village Queensbury 1 Street Address Stanton Nursing & Rehab Centre
0 Manner of Death 7 Natural Cause pi Accident n Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
...f..
Address f Z n
re 66/?6,cikeut,
Death Certificate Filed District Number Regisirmber
City, Town or Village Queensbury
❑Burial Date Cemetery or Crematory
❑Entombment Pine View Crematorium
Address
❑x Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ 7 Removal and/or Held
and/or Address
H Hold
to
0 Date Point of
NU Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
:, 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
ti`T, Remains are Shipped, If Other than Above
51 Address
Permission is hereby granted to dispose of the human re ains described abov indicated.
Date Issued / -yd,._ Registrar of Vital Statistics
y 9
__•:, (signature)
•.qe District Numberc-7 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W Date of Disposition $-a--it Place of Disposition at,(�
c 4..1 Cro-e'dnu—
W (address)
U)
CL (section) • (lot number)(-- (grave number)
pName of Sexton or Person in Charge of Premises 41461314r Jp,,,,wi{-Z (please print)
W Signature �',1, ."1- Title 0401N-rot-
(over)
DOH-1555(02/2004)