Tucker, Leslie NEW YORK STATE DEPARTMENT OF HEALTH
ranSlt Permit
Vital Records Section F Burial -
Name First Middle Last Sex
Leslie Tucker Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 14, 2013 82 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause n Accident Homicide n Suicide Undetermined Pending
l Circumstances Investigation
w Medical Certifier Name Title
G John J Layden MD
Address
6 Hearts Way,Queensbury,NY 12804
Death Certificate Filed District Number a r 60 1 Register Number
City, Town or Village Glens Falls Glens Falls 2 1 "2-
1:11 Burial Date Cemetery or Crematory
May 16, 2013 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
F"' Hold
U)
O Date Point of
N n Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
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
I Remains are Shipped, If Other than Above
$ Address
rt
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 I 'i 5 1 13 Registrar of Vital Statistics U.) c- .— W-..""
(signature)
District Number Glens Falls Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (�
W Date of Disposition b 17 f(3 Place of Disposition �, A L Ct�'`c '-_
2 (address)
W
CO
Ce (section) t num er) (grave number)
00 Name of Sexton or Pers n in Charge f Premises Aril _ Se4sitt
Z
(pleas print)
W L Title CitEkti
Signature
(over)
DOH-1555(02/2004)