Potvin, James NEW YORK STATE DEPARTMENT OF HEALTH ' �C
Vital Records Section ,,
I Burial - Transit Permit
Name First .Middle Last Sex
James M. Potvin Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 6,2017 84 War or Dates Korean
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death !Xi Natural Cause Accident Homicide F 1 Suicide Undetermined Pending
W Circumstances Investigation
n Medical Certifier Name Title
0 Daniel C.Larson
Address
HHHN,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 560 E 3 f 1
❑Burial Date Cemetery or Crematory
111 Entombment June 8,2017 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
5 [ Transportation Shipment
p by Common Destination
Carrier
U Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
i-. Remains are Shipped, If Other than Above
• Address
CC
tli
E>I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/ i ZO 11 Registrar of Vital Statistics
(signs re)
District Number 5 6 o I Place S F. I 1 S, N 7)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 611110 Place of Disposition Ti.,l��..•� Ci nq;1 sI -.
(address)
W
N
0 (section) pj (lot?umber) ( (grave number)
pName of Sexton or Person in Charge of Premises 6 ►I/ J&rae
W joe-
Signature (ple se print)
!mot Title CNE#br
(over)
DOH-1555(02/2004)