Cote, Leo NEW YORK STATE DEPARTMENT OF HEALTHXO
Vital Records Section E"` - Burial - Transit Permit
Name First Middle Last Sex
Leo Francis Cote Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 29, 2018 74 War or Dates
Place of Death Hospital, Vistitution or
uf City, Town or Village Queensbury Street Address 63 Cedar Court
• Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide El Undetermined ❑ Pending
Circumstances Investigation
g Medical Certifier Name Title
Andrew Garner, MD Dr.
Address
8 Harrison Ave. Glens Falls, NY 12801
Death Certificate Filed District Number aster Number
City, Town or Village Queensbury 1.ac n � (,O
❑Burial Date Cemetery or Crematory
October 5, 2018 Pine View Crematory
❑Entombment Address
--El Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z'❑ Removal and/or Held
• and/or Address
E Hold
CO Date Point of
❑Transportation Shipment
by Common Destination
• Carrier
ElDisinterment Date Cemetery Address
F El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r m s described aa- as indicated.
Date Issued 01, )(9.01 Registrar of Vital Statistics C L,
(signature)
District Numb '1 Place l -r\ C ( ?LAQQ_cJcYJ
I certify that the remains of the decedent identified above were disposed of in ac nce with this permit on:
Date of Disposition 10/05/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lo umber) s (grave number)
22 Name of Sexton or Person in Charge of Premises IhIJ pwv " l-1s#
� ` g
Signature Glil (pleas print)
Title N-M
(over)
DOH-1555 (02/2004)