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Porter, Leonard R ,_ . A@ n- )1 Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Leonard R.Porter Male Date of Death Age If Veteran of U.S.Armed Forces, 12/06/2023 80 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 64 Hadlock Pond Road,Fort Ann Town,New York 12827 ILI p Manner of Death ❑X Natural Cause Accident illHomicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 18 Burial Date Cemetery,Crematory or Facility Name 12/08/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation goRemoval Date Place Removed and/or and/or Held F Hold Address CO 0 O. Date Point of CO[]Transportation 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address ❑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 H Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/08/2023 Registrar of Vital Statistics .MiranzfaWferringsfraw(EfectronicaffySigned) (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— � Z Date of Disposition /Z� z3 Place of Disposition 1 ',1/O 't G� L'r,.1JQ. Nis 2 (address) W CC CC /section/_ jrnr) (grave number) gName of Sexton or Person in Charge of P miles eteiy�o✓41 Z (please print/ W Signature lde ' Title �j��YL S DOH-1555(07/18)p 1 of 2 w 0 4p. 2 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#