Leroux, John -411i
NEW YORK STATE DEPARTMENT OF HEALTH £ , f qi
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Arthur Leroux Male
Date of Death Age If Veteran of U.S.Armed Forces,
February 7, 2014 67 War or Dates
F- Place of Death Hospital, Institution or
irri City, Town or Village Saratoga Springs Street Address Mary's Haven
WManner of Death 0 Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
Gi; Patricia Ford,
Address
179 Lawrence St. Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village `150 I - )
❑Burial Date Cemetery or Crematory
February 10, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold Pine View Crematorium
CO Date Point of
per, ❑Transportation Shipment
00 by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
ERemains are Shipped, If Other than Above
Address
IL'
.1. Permission is hereby granted to dispose of the human rem d cr' ed ab¢IV indicat .
Date Issued021 i 020l L/ Registrar of Vital Statistics
(signature)
-EC I District Number L/50 1 Place C �-\--ki Cy( aicG o-,_ , n().
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-- Date of Disposition 02/10/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
60
re (section) jot number) (grave number)
0 Name of Sexton or Person .n Charge of Premises r.i r k'br
(pleilse print)
in
.:; Signature Title CKsti R
(over)
DOH-1555 (02/2004)