McCotter Sr., Leon NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leon E. McCotter Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/25/2013 76 years War or Dates 1954-57
F- Place of Death Hospital, Institution or
City, TowrrXiIIXX Clans FallsStreet Address Glans Falls Hospital
V Manner of Death N 1 Natural Cause 0 Accident Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
to Medical Certifier Name Title
41.
Dean A Reali M n
Address
3767 Main Street Warrensburg, N Y 12885
Death Certificate Filed District Number Register Number
City, Towr Rr yillR XX Glens Falls 01 • 268
NByrial Date Cemetery or Crematory
i ii ❑Entombment 06/78/2013 e View Cemetery -
Address
OCremation Queensbury, NY 12804 •
Date Place Removed
Z ri Removal and/or Held
' I—I an
d/or
�;; Address
Cl.)
Hold
0 Date Point of
65 Q Transportation
Shipment
E. by Common Destination
WI Carrier
[�Disinterment Date Cemetery Address •
-
Q Reinterment Date - Cemetery Address
<= Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
it Address
• 407 Bay Road Queensbury, NY
iii Name of Funeral Firm Making Disposition or to Whom
:1-- Remains are Shipped, If Other than Above
Address
i
Ilt
fl`. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/26/2013 Registrar of Vital Statistics ( CAX ,Q ,,A, ' "
(signature)
District Number 5601 Place Glens Falls/ IV y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6/28/13 Pine View Cemetery LEI Date of Disposition Place of Disposition
lit
(address)
to Mohican 578 1
CC (section) (lot number) (grave number)
cf Name of Sext or Person in Charge of Premises Connie L. Goedert
G.- 61 f (please print)
Signature: �'l�Zc,t.t.- '- �0 Title Superintendent
I .
(over)
DOH-1555 (02/2004) .