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Holstein, Leona Frances tt NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Leona Frances Holstein Female Date of Death Age If Veteran of U.S.Armed Forces, 05/05/2021 92 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc W Manner of Death C ©Natural Cause El Accident El Homicide 0 Suicide El Undetermined 0 Pending 11.1 Circumstances Investigation W Medical Certifier Name Title CI Rick Teetz MD Address 131 Lawrence St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 281 ❑Burial Date Cemetery,Crematory or Facility Name 05/06/2021 Pine View Crematorium ❑Entombment Address 0 Cremation Queensbury Town,New York 0 Donation Z ❑Removal Date Place Removed Q and/or and/or Held F.: N Hotd Address 0 a. Date Point of Cl)'❑Transportation Shipment Q by Common Carrier Destination El Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom i- Remains are Shipped,If Other than Above 2 Address CC W' a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/06/2021 Registrar of Vital Statistics ,7okn Paul'franck(E(ectronica1Ty Signed) (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 permitit/on: Z Date of Disposition 5 9-2/ Place of Disposition U'�:d e V, L r�iif�ii Z� W /addr / W CCCC (section) (lot nu ber) (grave number) 0 Name of Sexton or Person in Cha of Pre is l> r� �'© l (please print) W Signature /--i Title '� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) J. 14 7 6 3 Receipt Human remains of delivered on - ? , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#