Bulter, Leroy I •
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NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records • Burial - Transit Permit
Name First Middle Last Sex
Leroy I.Butler Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/08/2022 55 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Warrensburg Town Street Address 2 Scotts Drive,Warrensburg Town, New York 12885
'p Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ut Medical Certifier Name Title
a Kyle Leonard MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 2
❑Burial Date Cemetery,Crematory or Facility Name
01/12/2022 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
El and/or
Date Place Removed
and/or and/or Held
N Hold Address
0
IL Date Point of
(I) ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
El Disinterment
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
a Address
I
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/11/2022 Registrar of Vital Statistics Fame(aMLtoyd(ECectronicalTySigned)
(signature)
District Number 5660 Place Warrensburg, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition I/(Z I ZZ Place of Disposition T '+u.Ut" �ri,~
,2 (address)
W
CC
N (section) (lot number) C (grave number)
8 Name of Sexton or Person in Charge of P miles '�
Z L (Pleas rint/
W Signature Title re MAX
DOH-1555(07/18)p 1 of 2
r'%. .
Public Health Law Sec. 4145(2b)
Receipt
Human remains of L delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#