Collins, Leonard C SDI
NEW YORKSTATE DEPARTMENT OF HEALTH `"(- 7—F) Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Leonard C Collins Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/31/2022 89 Years War or Dates Navy
',, Place of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 163
Burial Date Cemetery,Crematory or Facility Name
11/01/2022 Pine View Crematory
Entombment Address
g Cremation Queensbury Town,New York
Donation
Date Place Removed
❑Removal
and/or and/or Held
Hold Address
2. Date Point of
ilk Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
fReinterment 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
' Remains are Shipped,If Other than Above
Address
` s
N
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2022 Registrar of Vital Statistics Caroline J(ilCegarde Barber(E(ectronica1Ty Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ll 12 ILL Place of Disposition ,,,1.L jt..--
Ili
a (address)
1' (section) del
numbe T\ (grave number)
8' Name of Sexton or Person in Charge of P ' es 4printi
W Signature Title iPeat.iVe,
DOH-1555(07/18)p 1 of 2
016370
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#