Leicht, Edgar Charles Jr. W '''''" ( LI- `
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edgar Charles Leicht Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/07/2023 87 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 10494 State Route 149,Fort Ann Town, New York 12827
p Manner of Death []Natural Cause []Accident []Homicide OSuicide ElUndetermined []Pending
W
U Circumstances I 'Investigation
W Medical Certifier Name Title
0 Aimee Mcmaster Nurse Practitioner,Acute Care
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 1
RBurial Date Cemetery,Crematory or Facility Name
01/10/2023 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
n. Date Point of
U) Transportation Shipment
Q by Common
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
f— Remains are Shipped,If Other than Above
g Address
CC
W
a.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2023 Registrar of Vital Statistics jenniferjackson gkctronicalySignerlJ
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II— `—'
1 4
Z Date of Disposition j/ii"lI3 Place of Disposition t-
l1J (address)
W
Cl)CC (section) (!o number) (grave number)
Name of Sexton or Person in Charge of Pr m " ' k., tf
(please p%nt)
W Title 67t ,
Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#