Girard, Leon NEW YORK STATE DEPARTMENT OF HEALTH , 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leon Jay Girard Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 18, 2013 48 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 225 White Birch Estates
Manner of Death rrlNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert H. Beaty, Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Moreau 145 2- 15
❑Burial Date Cemetery or Crematory
July 23, 2013 Pine View Crematory
❑Entombment Address
Cremation El Cremation Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain escribed above as indic ted.
7_as_i3 Registrar of Vital Statistics _A�n/�L ��CO
Date Issued 5- /
(signature)
District Number L/5 , 2- Place ( / I UAs,nl j�. St)uni 64C14/s FAA-A n/y /a2 O3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Perso in Charge of remises % 44IL '"
( lease print)
Signature7 Title CiZ)Jzdr2
(over)
DOH-1555 (02/2004)