Watsaw, Leo NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leo R. Watsaw Male
Date of Death Age If Veteran of U.S. Armed Forces,
Se t. 15 1997 73 War or Dates yw_II
Place of Death Hospital, Institution or
City, Tpmec000aw Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof, M.D.
Address
2 Broad St. Plaza, Glens Falls N.Y. 12801
Death Certificate Filed District Number Register Number
City, 19WIPPOPW Glens Falls 5601 y 2
Date Cemetery or Crematory
❑Burial Sept. 22, 1997 Pine View Cremator
Address
remation Queensb ury, N.Y. 12804
Date Place Removed
0 ❑Removal and/or Held
-- and/or Address
Hold
Q Date Point of
❑Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
.:]
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00017
Address
Rt. 28, North River, NY 12856
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 remains described s a ove . i ca d.
Date Issued 9/17/97 Registrar of Vital Statistics � ��
(signature)
. District Number 5601
Place City Clerk's Office, City of Glens Falls, N.Y. 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
jU Date of Disposition -02�- Place of Disposition /E4J [�'/P,E/jiJ D
(address)
LLJ
W
>> (section) (lot number) / (grave number)
GName of Sexto or Person in Charge of Premises �/�1] M� Z2Ed
Z (please print)
Signature Title G� Q S!
DOH-1555 (10/89) p. 1 of 2 VS-61