Leggett, Gary NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit/ ‘
1Vital Records Section
Name First Middle Last Sex
Gary F Leggett Male
Date of Death Age If Veteran of U.S.Armed Forces,
F August 27, 2013 (3 War or Dates x/Q
2 Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address Indian River Rehabilitation and
0 Manner of Death Natural Cause ❑ Accident ❑Homicide El Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Susan Sperry, M.D. NP
0 Address
17 Madison Street, Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City,Town or Village Granville ,5"7
A,5- 31
❑Burial Date Cemetery or Crematory
August 30, 2013 Pineview Crematorium
❑Entombment Address
i4 0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
and/or Address
i" Hold
YI Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
our Cemetery Address
o ❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
t= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Z
W Address
0.
Permission is here y granted to dispose of the human remains describ boy indicated.
Date Issued 9 i,3 Registrar of Vital Statistics ,,4
ignature)
District Number 5 7,0-- Place Granville,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 2/
wDate of Disposition 08/ /2013 Place of Disposition Pineview Crematorium
2 (address)
III
(section) .) nu er) -/ (grave number)
iName of Sexton or '•erso- in t- .'t a of Premises , 5 f.-,.MI C
C�+ /d
in (please pant) ,/�
Signature , ,.. Title /F7S
(over)
DOH-15` (02/2004)