Bennett, Leon Leroy St SW
4-- . 1,.. (LF)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Leon Leroy Bennett Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/18/2022 78 Years War or Dates
Place of Death I Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 121 Lamplighter Acres,Moreau Town,New York 12828
W Manner of Death Undetermined Pending
W �Natural Acc ident �Homicide Suicide
Circumstances Investigation
WMedical Certifier Name Title
O Thomas Coppens MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
,Town or Village Ce 4562 35
Burial Date Cemetery,Crematory or Facility Name
O6/21/2022 Pine View Crematory
Entombment Address
['Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
a Date Point of
Cl)❑Transportation Shipment
5 by Common
Carrier Destination
ODisinterment 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
1— Remains are Shipped,If Other than Above
2 Address
Q
u i
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics Leann,'4tc cage(FrctmnicaQySitnt4
(signature)
District Number 4562 -Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 6I74 I IL Place of Disposition 74 Y 1'
t.— /./`—
W (address)
W
Nre (section) i (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises ri- 4 i!•l'pL.- 4 rt
Z l Pease print)
W
Signature Title
DOH 1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named onburiarmit
Official Funeral Directors Reg.or License#