LeFevre, Benjamin r 3-)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Benjamin LeFevre Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/03/2021 87 Years War or Dates 1955-1957
1_ Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death ❑X Natural Cause D Accident Homicide 12 Suicide ❑Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Sergio Lema-Gutierrez MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 116
ElBurial Date Cemetery,Crematory or Facility Name
02/04/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
❑Donation
ZO Removal Date Place Removed
and/or and/or Held
- Hold Address
0
0 Date Point of
f/) �Transportation Shipment
p by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/04/2021 Registrar of Vital Statistics join l'au1Franckgkrtronicaf SWnerl)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition R—(e gip,? I Place of Disposition P rye v�i� (�I tj�l2' FL�
2 (address)
W
CC CC (section) / (lot number) i (grave number)
a /� P Name of Sexton or Person in Char ofrem• es 7 �\/�`7w'�e�-J r' U lE'c�C�
(please print)
W Signature a//� • Title ®r 7'
DOH-1555(07/18)p i of 2
,ry,
a
Public Health Law Sec. 4145(2b) 014505
Receipt
Human remains of % delivered on , 20
}'
Pine View Cemetery Representing the funeral home named on burial permit ,.
Official Funeral Directors Reg.or License#