Laubach, Leslie L Jr. t
NEW YORK STATE DEPARTMENT OF HEALTH F.,+ LA a Burial - Transit Permit
Bureau of Vital Records `- _1
Name First Middle Last Sex
Leslie L Laubach Jr Male
Date of Death Age If Veteran of US.Armed Forces,
11/01/2022 45 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death 0 Natural Cause ❑Accident 0 Homicide Suicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Romel Gobunsuy MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 637
Burial Date Cemetery,Crematory or Facility Name
11/03/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
ZO❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
LI. Date Point of
N❑Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
l` Remains are Shipped,If Other than Above
a Address
CC
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ft-
4___
W Date of Disposition (I�)Zj Place of Disposition /,�C�
2 (address)
uJ
N
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of P mises
dtiv--td
se print)
lU Signature Title
DOH-1555(07/18)p Id 2
01.6374
Public Health Law Sec. 4145(2b)
Receipt
Human remains of -"_ _ delivered on ,
20 ....
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#