Chase, Leon -ft fil2z1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'. Name First Middle Last Sex
Leon P. Chase Male
's Date of Death Age If Veteran of U.S. Armed Forces,
March 21,2016 70 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 3 Dixon Court
Manner of Death X Natural Cause Accident ❑Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
`:.� Glen Anderson,PA
Address
Queensbury,NY
;7 Death Certificate Filed District Number Register Number
City, Town or Village Queensbury, NY 5601 44-b
❑Burial Date Cemetery or Crematory
March 23, 2016 Pine View Crematorium
❑Entombment Address
LI Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z — Removal and/or Held
0 —and/or Address
f' Hold
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0 _ Date Point of
N Transportation Shipment
p by Common Destination
_ Carrier
Ti Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
Address
i •Permission is hereby granted to dispose of the human re a ns,de d a ye s indicated.
Date Issued j—, r t '- �
Registrar of Vital Statistics , ' "V p GU(signatur
District Number sc„-t. Place . L nAVIti n
I certify that the remains of the decedent identified above,.1.. ere disposed of in accord-. ' i this permit on:
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W Date of Disposition 3)vj/It, Place of Disposition ��,�d ,, , dtitr--
2 (address)
W
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cc (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises f1. St Wit
Z i (please print)
W
Signature Title 0M4174
(over)
DOH-1555(02/2004)
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