Fordham, LeRoy NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
`<' Name First Middle Last Sex
LeRoy Edwards Fordham Male
Date of Death Age If Veteran of U.S. Armed Forces,
•'r December 12, 2014 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Manner of Death
Street Address 21 Kenwood Circle
I�1 Natural Cause Accident E Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
'� . Medical Certifier Name
Title
Gwendolyn Morris-Dickinson,PA
r a Address
Fort Edward,NY
' Death Certificate Filed District Number Register Number
ACity, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
December 16, 2014 Pine View Crematorium
❑Entombment Address
ID Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO U Removal and/or Held
and/or Address
F Hold
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O Date Point of
Nn Transportation Shipment
as by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
f Name of Funeral Home Regan Denny Stafford Funeral Home 01443
e Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1i Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described(('' above as indicated.
Date Issued 1 -I lc I+chi v `mil ALA....,
Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1Z116i(y Place of Disposition AZ i--- Cry-hir,
2 (address)
W
Cl)
1Y (section) Arot number) (grave number)
O Name of Sexton or Person in Char a of Premises eit+fs}f'r--
Z
Title4r (pie s c'izte print)
"'
Signature
(over)
DOH-1555(02/2004)