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Potter, Jane Marie NEW YORK STATE DEPARTMENT OF HEALTH s- I•J? Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Jane Marie Potter Female Date of Death Age If Veteran of U.S.Armed Forces, 10/05/2020 78 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death © W Natural Cause Accident Homicide Suicide 1=1 Undetermined 1=1 Pending V Circumstances Investigation W Medical Certifier Name Title Q Sean Bain MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 459 ❑Burial Date Cemetery,Crematory or Facility Name 10/08/2020 Pine View Crematory n Entombment Address X❑Cremation Queensbury Town,New York ElDonation 1:1Removal Date Place Removed and/or and/or Held - Hold Address 0 co ❑Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom E-. Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/08/2020 Registrar of Vital Statistics Men Andrew Curtis(Electronically 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: Z Date of Disposition (0 li iio Place of Disposition g (address) W N CC (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Prem. rs Z (plijase print) W Signature Title lr W hVit- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 4 0 5.3 9 • Receipt Human remains of - delivered on 2 , 20,E Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# I i;' :'t !(,