Dornan, Leonard NEW YORK STATE DEPARTMENT OF HEALTH _ z * CO b
Vital Records Section Burial - Transit Permit
Name First ,,, Middle Last Sex
Leonard Richard Dornan Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 22, 2012 80 War or Dates Korea
i"' Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 6 Hillcrest Drive
W, tY 9 9 ry
WManner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide 1-1 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI' David Foote Md,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
'P- City, Town or Village k►Y1 s b Li r 3-7 60,)— /1
❑Burial Date Cemetery or Crematory
September 28, 2012 Pine View Crematorium
❑Entombment® Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Z Date Point of
e ❑ 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
1 Remains are Shipped, If Other than Above
2 Address
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il"li Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9-4(a- 04—Registrar of Vital Statistics -e 4 , /d� �
oN (signature)
District Number 5ry6,� Place , fyy jay!
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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uj Date of Disposition /e11 i 112- Place of Disposition Z1144 IJ C 4 or(✓•--
2 (address)
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tom:
:• (section) (bt number)��"K if (grave number)
0; Name of Sexton or Per on in Charge o Premises
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Z lease print)
W Signature - Title L4 �n -
(over)
DOH-1555 (02/2004)