Leroux, Louise %"
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.�� Name First Middle Last Sex
<., Louise Fannie Leroux Female
f: Date of Death Age If Veteran of U.S. Armed Forces,
''
, � August 7,2016 78 War or Dates
' �' Place of Death Hospital, Institution or
Ys City, Town or Village Glens Falls Street Address Glens Falls Hospital
-, Manner of Death n Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1 Pending
`r: Circumstances Investigation
". Medical Certifier Name Title
.Steinhacker PA
Address
$0 100 Park Street,Glens Falls,NY 12801
{fDeath Certificate Filed District Numbe �t Regisier,f�
City, Town or Village Glens Falls 1—J6`
®Burial Date Cemetery or Crematory
August 11, 2016 , Pine View Cemetery
❑Entombment- Address
❑Cremation Quaker Road Queensbury, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
F' Hold
CO
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
pi Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
, ; Permit Issued to Registration Number
'`' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
f' Address
1��F 407 Bay Road,Queensbury, NY 12804
f
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f Permission is hereby g anted to dispose of the human remains de ri a abo e a ' ated.
f'f'
R Date Issued 08.24<6. Registrar of Vital Statistics
1 (signature)
//
-» District Number �/vD/ Place p�,�y,o �ir-�6<J�{, , /00-c4.) lort,s1‘.---
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 8/1 1 /1 6 Place of Disposition Pine View Cemetery, Oueensbury, NY
W (address)
Mohawk 18A 1
W (section) (lot number) (grave number)
QName of Se n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W f—'
Signature Title Cemetery Superintendent
UUU (over)
DOH-1555(02/2004)