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Potvin, Terry Lee
NEWYORK STATE DEPARTMENT OF HEALTH - _. _ Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Terry Lee Potvin Female Date of Death Age If Veteran of U.S.Armed Forces, 03/05/2020 57 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation Q Medical Certifier Name Title Nawed Siddiqui MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Villa a Glens Falls 5601 113 ❑Burial Date Cemetery,Crematory or Facility Name ❑ 03/09/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation O ❑ Date Place Removed Removal r and/or and/or Held N Hold Address Q) ❑Transportation Date Point of $ by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition orto Whom I.. Remains are Shipped,If Other than Above Address IIE n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/09/2020 Registrar of Vital Statistics WgbertAndrew Curtis(ECectronically Signed) (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: H Z Date of Disposition Place of Disposition r W (address) W (section/ (/ot number) (grave number/ CName of Sexton or P son in Ch a of Premises e�M S� (p/ease print/Z W Signature r Title C.fe"nQ o DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) J�•3 4 0 7 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#