Lefebvre, Scott Robert w
f
N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Scott Robert Lefebvre Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/28/2020 53 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 14 Hudson Avenue,Glens Falls,New York 12801
p Manner of Death ❑ Natural Cause ❑Accident ❑Homicide ❑Suicide 1=1Undetermined ❑X Pending
V Circumstances Investigation
lU Medical Certifier Name Title
G Timothy Murphy Coroner
Address
52 HAVILAND AVE,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 492
❑Burial Date Cemetery,Crematory or Facility Name
11/02/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N 1-1
Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
W
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2020 Registrar of Vital Statistics itry6ert,?rulreWCurtzr(EkaronicaQSrgue&
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition II/I!TO Place of Disposition
2 (address)
W
(section) lot number/ (grave number)
CName of Sexton or Person in Charg f Premises r' J�'+'J�
Z (pie*print) /
W Signature �I ' Title L � �
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
� 4 6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#