Legault, Roland Joseph LF
NEWYORKSTATEDEPARTMENTOFHEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Last I Sex
Roland Joseph Legault
Date of Death Male
Age If Veteran of U.S.Armed Forces,
04/08/2022 84 Years War or Dates 1958 to 1963
f.. Plae of Death Hospital,Institution or
wCity,Town or Village Glens Falls Street Address Glens Falls Hospital
11.1
O Manner of Death Natural Cause Accident I I Homicide Suicide rEl l n Pending
Undetermined
Circumstances Investigation
Ili Medical Certifier Name
CI
Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
DeaHth Certificate Filed Cit Of Glens Falls District Number
City,Town or Village X 5601 Register Number
205
Burial Date Cemetery,Crematory or Facility Name
04/11/2022 Plne View Crematory
Entombment Address —
aCremation Queensbury Town,New York
=ODonation
Z❑Removal Date Place Removed
;; and/or and/or Held
Hold Address
0
a Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
C
!El
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/11/2022 Registrar of Vital Statistics 914egan NoCin(ECectronicallySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
ILI
Date of Disposition yt1i2,)ZZ Place of Disposition r1.+stU`► , `
W (address)
C; (section/ (tot number) (grave number)
0` Name of Sexton or Person in Charge of Premises (si S „��
Z' (plea e print)
lU Signature `� ems./ `rli - ^,L
Title
DOH-1555(07/18)p i of 2
i 1. — e ri
Public Health Law Sec. 4145(2b)
IReceipt
Human remains of delivered on , ,
20 ; `-_
1 %
Pine View Cemetery Representing the funeral home named onburial.permit
Official Funeral Directors Reg.or License# t: i