Couture, Leo •
° W YORK STATE •
a DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last
iiiiiiiii
Leo George Couture Sex Male
iiii,i,iiDate of Death Age If Veteran of U.S.Armed Forces,
3-11-87 59 Yr
War or Dates WW II & Korean Conflict
Place of Death Hospital, Institution or
Au City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
P. Cause of Death
3,14 Cardio Pulmonary arrest
l3 Medical Certifier Name Title
o William A. Tedesco M.D.
s
17 Pine St. , Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village City of Glens Falls \5E4 / / ,..1—
ii Date 3_12-87 Cerrletery or Crematory
El Burial Pine Crematorium
®Cremation
Address ...........:..:.....:.....:.............:.:............:..............::....:.........:.................:..::..............:.
Town of Queensbury, NY
.: .............................;.................:..........................:.............:::.........:...:::..
..:...::.::.........:.:.......:.::.......::.
z' Date Place Removed
01 0 Removal and/or Held
and/or d/or Hold ....................
:: Address
Cl)
r. : Date Point of
y) ❑Transportation by
- Shipment
D; Common Carrier
Destination
.........................................:::::Date ..................................................... ... ... .......................................................................................................
El Disinterment Cemetery Address
El Reinterment Date Cemetery Address
...::...:.:............
Permit Issued to Registration Number
>.:: Name of Funeral Firm Regan & Denny, Inc. 02883
Address
........................
Quaker Road, Glens Falls, NY 12801
.............................
? Name of Funeral Firm Making Disposition or to Whom
i2i Remains are Shipped, If Other than Above
AU
Address
its:
. ....................................
Permission Is hereby granted to dispose of the dead hu•• . i rem ns describe• above as indicated.
Date Issued 3 /2- ,e", Registrar of Vital Statistics . /" ' , .111110.4
nature)
District Number Place t2,__.-- `` .7. _A8/
I certify that the remains of the decedent identified above were disposed of in ac?Lc:7
��
nce with this permit on:
w' Date of Disposition %/2..J1 ) Place of Disposition f',,?.x. 'L. --Y ,A- c'l-Ct�• ,,� ; i /,i i/ t-'u k_..���r.uy
2< (address)ILI
1 .•
X (section) (lot number) (grave number)
pName of Secton or Person in Charge of Premises /4)r1 r) e. -.1
Z i (please print) -
11,1 Signature (. -,,....y._../ Title (..:/), ,-r--k-c-70 $—
DOH- 1555 (9/86)p 1 of 2(formerly VS-61)