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Liebi, Daniel W NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Daniel W. Liebl Male Date of Death Age If Veteran of U.S.Armed Forces, 11/16/2023 89 Years War or Dates 1955-1957 Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek 11.1 p Manner of Death 1=1 Natural Cause Accident Homicide Suicide Undetermined ❑Pending W ✓ I—ICircumstances Investigation LU Medical Certifier Name Title CI Leah Terry NP Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 48 Burial Date Cemetery,Crematory or Facility Name 11/17/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held - Hold Address O _ a Date Point of (/)Dransportation p by Common Shipment Carrier Destination Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/17/2023 Registrar of Vital Statistics Jean M Comstock(Electronically Signed) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- W Date of Disposition jr}p-) .)3 Place of Disposition � v c 2 (address) uJ CC N (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises TQC;~4 SEV,w Z / (please print) W Signature ` Title CirC ev qt(- DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) w Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#