Potter, Marian NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
7r4 Name First Middle Last Sex
401. Marian W Potter Female
7 Date of Death Age If Veteran of U.S. Armed Forces,
Ot 12/06/2018 95 Years War or Dates
Place of Death Hospital, Institution or
" City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
Manner of Death IX Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
IT
L—ICircumstances L. .i Investigation
Medical Certifier Name Title
Eric Sante!! NP
Address
131 Lawrence St,Saratoga Springs,New York 12866
:47) Death Certificate Filed
l District Number Register Number
:.! City,Town or Village Saratoga Springs 4501 638
"0 Burial Date Cemetery or Crematory
12/0/2018 Pine View Crematorium
*-1 0 Entombment Address
, OCremation Queensbury Town, New York
Date Place Removed
n Removal and/or Held i....„and/or Address
61 Hold
SY Date Point of
ri 0 Transportation Shipment
5 by Common Destination
rl-- Carrier
Disinterment Date Cemetery Address
%, 0
Ei Reinterment Date Cemetery Address
Permit Issued to Registration Number
,,, Name of Funeral Home Carleton Funeral Home Inc 00281
1. Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
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.
Date Issued 12/07/2018 Registrar of Vital Statistics jofin 4)EratickrEactroniza45,Sigtraci
(signature)
District Number 4-501 Place Saratoga Springs, New York
ei0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1..0
E Date of Disposition 4-40- 1,5 Place of Disposition pi e.. VI eAd Cre.,1141 of Y
(address)
1.4.1
I -(section) , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises cit 1410 Sqt.Xff.5
(please print)
,
Signature Title Clit,ivIci4V-
(over)
DOH-1555 (02/2004)