Leonard, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH i 56
Vital Records Section Burial - Transit Permit
'jy Name First Middle Last Sex
f Beatrice L. Leonard Female
%s Date of Death Age If Veteran of U.S. Armed Forces,
�' August 5,2016 84 War or Dates
Place of Death
3h Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause ❑Accident ElHomicide ❑SuicideFTUndetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
,
Address
100 Broad Street,Glens Falls,NY 12801
fff Death Certificate Filed District Number Rent�rtmber
,n, City, Town or Village Glens Falls 5601 (�-J�U
❑Burial Date Cemetery or Crematory
❑Entombment August 8,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
',,.m•
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
IIAddress
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
:; Permission is hereby g anted to dispose of the human remains described ov ndicated.
I? 44/ '
Date Issued F f)r 2di-c Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
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�/b�J6 Place of Disposition Zadit✓ —.'
2 (address)
W
Vi
(section) (lot number) c (grave number)
pName of Sexton or Person in Charge of Premises 'ate Jim./rl
Z se print)
W Signature Title `(Ik'61UIL
(over)
DOH-1555(02/2004)