Leslie, John 1 ,5rO
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ` Sex
John R. Leslie Male
i<': Date of Death Age If Veteran of U.S. Armed Forces,
06 / 30 / 2018 59 War or Dates N/A
14 Place of Death Hospital, Institution or
j City, Town or Village Saratoga Springs Street Address 335 Jefferson Street, C12
aManner of Death❑Natural Cause ❑Accident 0 Homicide E Suicide �Undetermined 0 Pending
t Circumstances Investigation
la
iti Medical Certifier Name Title
Q Michael Sikirica MD
Address
50 Broad St, Waterford, NY 12188
Death Certificate Filed District Number Register Number
s3i City, Town or Village Saratoga Springs 41 S( ,2)--)
iiiiDate Cemetery or Crematory
l3urial 07 / 05 / 2018
Pine View Crematory
ft uEntombment Address
;` nCremation Queensbury, NY
Date Place Removed
4❑Removal and/or Held
and/or Address
i
Hold
0 Date Point of
it 0 Transportation Shipment
. by Common Destination
Carrier
0 Disinterment Date Cemetery Address
iiill0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
`> Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp., NY 12866
ig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
te
Permission is he eby ranted to dispose of the human rern ...s c ed aev indicat .
Date Issued Registrar of Vital Statistics
(signature)
iM District Number 4 5-O' Place Saratoga Springs , New York
Zili
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
100
111 Date of Disposition 711 lI? Place of Disposition i, V,.- Lit.,
a (address)
Ili
tC (section) (lot mber) (grave number)
0 Name of Sexton or Person in Charge of Premises �{""
(please print) •
Signature A Jim- Title ittcn ot
(over)
DOH-1555 (02/2004)