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Leroux, Andre Ivuw NEW YORK STATE DEPARTMENT OF HEALTH ' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Andre Paul-Ovila Leroux Male Date of Death Age If Veteran of U.S. Armed Forces, December 16, 2018 25 War or Dates Place of Death Hospital, Institution or City, Town or Village Moreau Street Address 5 Squires Road Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined Pending U.ICircumstances Investigation Medical Certifier Name Title Michael Sikirica , Dr. Address 50 Broad Street Ste 1 Waterford, NY 12188 Death Certificate Filed District Number Register Number City, Town or Village Moreau y 540 2 Co U ❑Burial Date Cemetery or Crematory December 19, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 3 ❑ Removal and/or Held and/or Address Hold Date Point of ili ❑Transportation Shipment lit by Common Destination Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 1: Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /�l/9 Ji �5 Registrar of Vital Statistics /Ll �►. ---_ (signature) District Number 4l j to Z Place %O(j n rJ F y/1/1 d f C 1,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12/19/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number)1 it (grave number) Name of Sexton or Person in Charge of Premises c�^`� I �rvnt �j p (please print) Signature (.�- Title C�2/~• °� (over) DOH-1555 (02/2004)