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Potvin, Lucinda IUU NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Lucinda Ann Potvin Female Date of Death Age If Veteran of U.S. Armed Forces, December 18, 2018 57 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death .i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 0 Pending Circumstances Investigation § Medical Certifier Name Title Terry Comeau, Address 1340 State Route 9 Lake George, NY 12845 Death Certificate Filed District Number � � Register Number City, Town or Village Glens Falls 0 Burial Date Cemetery or Crematory December 20, 2018 Pine View Crematory ['Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment )- by Common Destination 0 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address } Permission is hereby granted to dispose of the human remains described above as indicated.c� Date Issued )4?�j)•z}ic.Registrar of Vital Statistics 1.")� (}J .A 1'W (signature) District Number S 60 ) Place 6 is21n.S Vc.IA\,s-) k L) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 12/20/2018 Place of Disposition Quaker Road Queensbury,NY 12804 M; (address) (section) (lotumber) 1v1.c-L�t I iiu� (' (grave number) Name of Sexton or Person in Charge of Premises (please print) W- Signature 71 A- Title CFerc- " (over) DOH-1555 (02/2004)