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Riley, Leo T
(.1:Trz) It /0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Leo T.Riley Male Date of Death Age If Veteran of U.S.Armed Forces, 01/23/2024 67 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Hudson Falls Village Street Address 30 Delaware Avenue,Hudson Falls Village,New York 12839 ,p Manner of Death Z Natural Cause []Accident El Homicide 0Suicide FlUndetermined []Pending V I—ICircumstances I 'Investigation Q Medical Certifier Name Title 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 Burial Date Cemetery,Crematory or Facility Name 01/26/2024 Pine View Crematorium []Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held - Hold Address 0 O. Date Point of Li)❑Transportation IT) by Common Shipment Carrier Destination []Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/26/2024 Registrar of Vital Statistics Cynthia Bardin(Electronically Signed) (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: l- W Date of Disposition ('joI jt� Place of Disposition -r r,) 2 (address) W CC (section) (lot number/ (grave number) / Name of Sexton or Person in Charge of Pr !" 31)1.. —_ Z lease print) /�+�,� ttJ Signature Title G "1� c DOH-1555(07/18)p 1 of 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#