Barney Jr, Leonard NEW YORK STATE DEPARTMENT OF HEALTH ,� III
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leonard Joseph Barney Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
February 27, 2014 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 160 Crowley Road
Manner of Death J Natural Cause Accident El Homicide 0 Suicide Undetermined Pending
f Circumstances Investigation
111 Medical Certifier Name Title
iZt Amy Hogan-Moulton MD,
` Address
2 Broad Street Plaza Glens Falls, NY 12801
� Death Certificate Filed District Number Register Number
City, Town or Village b 7 G a, n S—
_.. ❑Burial Date Cemetery or Crematory
March 3, 2014 Pine View Crematorium
0 Entombment Address
F,MCremation Quaker Road Queensbury NY 12804
FAil Date Place Removed
ztri Removal and/or Held
and/or Address
Hold
r_ Date Point of
❑Transportation Shipment
by Common Destination
la 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
ep Name of Funeral Firm Making Disposition or to Whom
R Remains are Shipped, If Other than Above
Address
i
Iti
i,. Permission is ereby granted to dispose of the human remains described above as indicated.
Registrar of Vital Statistics n C = ��s
3 Date Issued 3 3 / ij i g !-
(signature)
District Number 5- 76 a Place nLu-,` ;
I certify that-the remains of the decedent identified above were disposed of in accordance with this permit on.
t Date of Disposition 03/03/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person ' Charge f Premises c me JAI*
Tease print)
go
igl Signature Title c2eihrZ
(over)
DOH-1555 (02/2004)