Mansell, Leonard Thomas 14 Lii3
NEWYORKSTATEDEPARTMENTOFHEALTH \` Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Leonard Thomas Mansell Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/28/2022 75 Years War or Dates 1965-1969
H Place of Death Hospital,Institution or
Z City,Town or Village Hudson Fats Village Street Address 264 Main Street A3,Hudson Falls Village,New York 12839
W Manner of Death
� 111 Natural Cause Accident n Homicide nSuicide nUndetermined nPending
W I1 ''Circumstances II ''Investigation
U
W Medical Certifier Name Title
O Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 47
FBurial I Date Cemetery,Crematory or Facility Name
12/01/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
U)
0
Q. Date Point of
U)fTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
nDisinterment
Date Cemetery Address
E Reinterment
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
—. Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2022 Registrar of Vtal Statistics Cynthia,?(Bard-in(EhectronicalTySigned)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II- �^'
Z Date of Disposition 12 11 I Z L Place of Disposition L ''ti 1 l M i c—
W
2 (address)
W S
NCr /section/ L J (tot number) (grave number)
O Name of Sexton or Person in Charge of Premises ^ L— i t
Z /pte$se print)
W �� Title �7�/YV) �G 1
Signature
DOH-1555(o7/18)p 1 of 2
0 1• fv 3 /
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#