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Brochu, Leo Clement
I.C.- NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Leo Clement Brochu Male Date of Death Age If Veteran of U.S.Armed Forces, 12/30/2020 96 Years War or Dates Place of Death Hospital,Institution or lU City,Town or Village Glens Falls Street Address 25 Harrison Avenue,Glens Falls,New York 12801 0 Manner of Death ❑7 Natural Cause ❑Accident 0 Homicide E Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Thomas Coppens MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 608 ©Burial Date Cemetery,Crematory or Facility Name 01/02/2021 Pine View Cemetery Entombment Address Cremation Queensbury,New York Donation Z El Removal Date Place Removed and/or and/or Held N Hold Address 0 ❑Transportation Date Point of 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address 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 j.... Remains are Shipped,If Other than Above Address #'' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/31/2020 Registrar of Vital Statistics Rp6ert,1nnrew Clans gYectronicaf Signt'42 (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: Date of Disposition 1 �2�7 07 Place of Disposition 21 Quaker Rd Queensbury, NY 1 28 0 4 2 (address) th Mohican 84 G 1 it it Mohican (lot number) (grave number) Name of Sexton or Person in Charge of Premises Connie GoedPrt Z � (please print) W Signature (mil .c2 , Q a Title Super ntendent DOH-1555 lo7/18)p 1 of 2 Public Health Law Sec. 4145(2b) u12835 Receipt Human remains of I delivered , 20 Pie View Cemetery Representing the funeral home aired on burial permit Oficial Funeral Directors Reg.or License#