Cleckner, Leone NEW YORK STATE DEPARTMENT OF HEALTH, ` 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leone A. Cleckner Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 22, 2013 96 War or Dates
f_ Place of Death Hospital, Institution or
LZ City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre
p Manner of Death U Natural Cause ❑Accident []Homicide Suicide n Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
G Roslyn Socolof MD
Address
152 Sherman Avenue,Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 c9
❑Burial Date Cemetery or Crematory
February 25, 2013 Q(NE \I i C zokut* 2 ui w _,
❑Entombment Address
❑X Cremation
Date Place Removed
Z Removal and/or Held
and/or Address
F" Hold
N
O Date Point of
yTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home I 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
O.,
Permission is hereby granted to dispose of the human r mains described ab e as indicated.
Date Issued �(221(f (j� Registrar of Vital Statistics 4. 11-`'
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition -d6 13 Place of Disposition j jv4. ,.,,/ c�dg U'y-a k/
2 (address)
W
CO
Ce
(section) 4_ (lot umber) f (grave number)
G
O Name of Sexton o ers i r e of Premises "f [j� �j,�9,/L4
'Z lease pr' t).
Signature Title C,e49-._ f&J
(over)
DOH-1555(02/2004)