Bredenko, LeRoy P NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records �.
Name First Middle Last Sex
LeRoy P.Bredenko Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2022 69 Years War or Dates
E.. Place of Death Hospital,Institution or
WCity,Town or Village Potsdam Village Street Address 3 Debra Drive A216, Potsdam Village, New York 13676
p• Manner of Death ❑X Natural Cause Accident Ei Homicide Suicide Undetermined Pending
U I—ICircumstances Investigation
GMedical Certifier Name Title
June Wood Coroner
Address
2817 State Highway 72, Potsdam Town,New York 13676
Death Certificate Filed Village Of Potsdam District Number Register Number
City,Town or Village 4429 181
Burial Date Cemetery,Crematory or Facility Name
11/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
O. Date Point of
U)nTransportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/10/2022 Registrar of Vital Statistics Lori Queor(Electronically Signed)
/signature/
District Number 4429 Place Village Of Potsdam
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition fl Ill IZL Place of Disposition ,��'�t6L /lF-----
2 (address)
W
U)
O /section/ /� (lotnumber�. (grave number)
C Name of Sexton or Person in Charge of Pre ises `/ F1t
Z (lease print)IL Signature Title /P, *Tt2
DOH-1555(07/18)p t of 2
:? q
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
home named on burial permit
Pine View Cemetery Representing the funeral
Official Funeral Directors Reg. or License#