Carpenter, Leslie f
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TransitPermit
Vital Records Section
Name First Middle Last Sex
Leslie Atwood Carpenter Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 26,2013 75 War or Dates
il-= Place of Death Hospital, Institution or
Z= City, Town or Village Glens Falls Street Address Glens Falls Hospital
111
Manner of Death Undetermined Pending
Natural Cause Accident Homicide J I Suicide
*111 Circumstances Investigation
411 Medical Certifier Name Title
Eric Pillemer
Address
CR Wood Cancer Center,Glens Falls,NY 12801
'`� Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 J
❑Burial Date Cemetery or Crematory
Entombment December 30,2013 Pine View Cemetery
Address
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
tn
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
fY;
11.1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 2/3 1 l l Registrar of Vital Statistics t/<7 v2 w. --,
(signature)
,, District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition i/ ill Place of Disposition U3«, C«Ltbry
W (address)
Cl)
re (section) 4 Timber) r (grave number)
nS
a Name ofSexton or Person in harge of Premises r L+irt}'
wZ (pl se print)
Signature f6-- Title t;il 1 ,
(over)
DOH-1555 (02/2004)