Potvin, Joseph NEW YORK STATE DEPARTMENT OF HEALTH Burial t P'@ yy
Vital Records Section urial - Transit rmit
1 Name First Middle - Last Sex
Joseph William Potvin Male
Date of Death Age If Veteran of U.S.Armed Forces,
June 16, 2017 75 War or Dates
Place of Death Hospital, Institution or
j
ut City, Town or Village Hudson Falls Street Address 16 Circular Drive
T Manner of Death a Natural Cause El Accident D Homicide Ej Suicide Undetermined Pending
ilk
,lc Circumstances Investigation
W Medical Certifier Name Title
It. AmyHogan-Moulton, M.D. Dr.
Address
2 Broad St. Plaza Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 7 Z C /6
Burial Date Cemetery or Crematory
June 19, 2017 Pine View Crematorium
Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
H Hold
Date Point of
Transportation Shipment
by Common Destination
'0, Carrier
F 14,
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
: , Permit Issued to Registration Number
• Name of Funeral Home Carleton Funeral Home, Inc. 00281
T Address
4q Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
N Name of Funeral Firm Making Disposition or to Whom
ih- Remains are Shipped, If Other than Above
2H Address
Permission is hereby granted to dispose of the human rema" described above as indicated.
• Date Issued 6-/ -/7 Registrar of Vital Statistics c _o�- (,c�a
j t (signature)
• :' District Number „-7 4 Place h ' 1'
,77
'- - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
pt Date of Disposition 06/19/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
tll
firi
ie (section) (lot number) (grave number)
/'
Name of Sexton or Person in Charge of Premi es G hr.s{ 4^ c t 4at
(pie se print)
Signature / Title C P'
(over)
DOH-1555 (02/2004)
I