LeClair, Nathalie NEW YORK STATE DEPARTMENT OF HEALTH �' .
Vital Records Section _ Burial - Transit Permit
N.
Name First Middle Last Sex
Nathalie LeClair Female
Date of Death Age If Veteran of U.S. Armed Forces,
rNovember 10, 2012 86 War or Dates
y.. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 33 Petrie Lane
BS
im Manner of Death AI Natural Cause Accident Homicide Suicide n Undetermined Pending
tB Circumstances 'Investigation
CI
` Medi I Certifier, NapaR Title
+�``\6Address
Death Certifi�ate rr Filed District Number inter Number
4 City, Town or Village Queensbury,NY 5657
+❑Burial Date Cemetery or Crematory
❑Entombment November 15,2012 Pine View Crematory
Address
N Cremation Quaker Road, Queensbury,NY 12801
Date Place Removed
Z I +Removal and/or Held
2 and/or Address
H Hold
N
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
i 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
t Remains are Shipped, If Other than Above
`2 Address
re
:, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issue 11�1ARegistrar of Vital Statistics Cam__ ek C)--1Sc-Z.c J--..„
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition l(l lb j iZ Place of Disposition
� 'C�nL0uv �rc,rn„�Q�'i kJ)."
W (address)
N
Ce
Z Name of Sexton or Person in Charge of Premises (section) (lot number) (grave number)
Aei-A4.)011,-. �-
(ple se print)
W
1.1'4'
SignaturerL Title CM M4o�,
(over)
DOH-1555(02/2004)