Harrison, Leroy W 4f3S
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NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Leroy W.Harrison Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/08/2023 81 Years War or Dates 1959-1961
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
EU
p Manner of Death El Natural Cause EAccident El Homicide Suicide FlUndetermined riPending
111
Circumstances Investigation
1,11 Medical Certifier Name Title
a Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 1 5601 10
Burial Date Cemetery,Crematory or Facility Name
v 01/10/2023 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
01:1and/or and/or Held
Hold Address
U ❑Transportation Date Point of
ZS by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
Date Cemetery Address
til Reinterment
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
m. Address
Er
t
!L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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:
F—' 7
WDate of Disposition I 110 t'3. Place of Disposition -1.7 � (4-,--__
a (address)
LU
tr (section) 4 (lobumber) (grave number)
U Name of Sexton or Person in Char of Premises 7pr/nt)
Signature Title �r'f'
DOH-1555(07/18)p 1 of 2
11 r 8 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on f , 20
Pine View Cemetery Representing the funeral home named pri,bitrial permit
Official Funeral Directors Reg.or License# '