Grant, Leo William 1W
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Leo William Grant Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2021 78 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
`p Manner of Death ❑. Natural Cause El Accident ❑ Homicide Suicide jr-iUndetermined ❑Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 41
❑Burial Date Cemetery,Crematory or Facility Name
02/09/2021 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
o- Date Point of
t/)11 Transportation
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
p.. Remains are Shipped,If Other than Above
_• Address
CC
W
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2021 Registrar of Vital Statistics Carolinex/garde Barger(E/ctronicalySWned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 2j101 Zf Place of Disposition IL ;iti
W address)
W
Cl)CC (section) (lot number/ (grave number)
0 Name of Sexton or Person in Charge of Premises
Z (p/ease riot)
W Signature Title l'M"r As vls,
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) a 1 4 S 2 7
Receipt
Human remains of • delivered on , 20
•
Pine View Cemetery Representing the funeral home named on burial permit -j
Official Funeral Directors Reg.or License#