Liebl, William it Gv L
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Name First Middle Last Sex Male
William S. Liebl
Date of Death Age i If Veteran of U.S. Armed Forces,
> 4/2/2013 80 I War or Dates 1953-1959
Place of Death I Hospital, Institution or
Z Cilaclift0IMIlla Glens Falls Street Address Glens Falls Hospital
Manner of Death+2(j Natural Cause Q Accident El Homicide El Suicide 0 Undetermined 17❑Pending
Circumstances Investigation
Ili Medical Certifier Name Title
Christopher Hoy M.D.
, Address
102 Park St., Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
r. City) Xi r Glens Falls I S601 IV I
Date Cemetery or Crematory
❑Burial 4/8/2013 Pine View Crematory
Address
0 Cremation I Queensbury,NY
Date Place Removed
0❑Removal and/or Held
,• and/or Address
rz Hold
0 : Date ' Point of
t Q Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date � Cemetery Address
0 Reinterment Date Cemetery Address
', Permit Issued to , Registration Number
:1 Name of Funeral Home Brewer Funeral Home,Inc, _ 00211
Address
24 Church St., Lake Luzerne,NY 12846
Name of Funeral Firm Making Disposition or to Whom
....C. Remains are Shipped. If Other than Above
Address
14.1
1
Permission is hereby granted to dispose of the human remains described above as indicated.
: Date Issued `1 /4-t (r 3 Registrar of Vital Statistics Cam ',A".
(signature)
District Number 5 be i Place 6 5 \A S , ivy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition L! le-I Place of Disposition114 ' frt tdr.ti
2 (address)
UM
CC (section) (lot number --- (grave number)
• Name of Sexton or Person in Charge of Premises // - .?nritt
2 (please print)
2 /� L Title (1'L Mt}l e
• Signature [
DOH-1555 (10/89) p. 1 of 2 VS-61