Potter, Beverly NEW YORK STATE DEPARTMENT OF HEALTH # 70
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
Beverly A. Potter Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 28,2016 84 War or Dates
. Place of Death Hospital, InstitutiorW[irren Center For Rehabilitation And
City, Town or Village Street Address Nursing'
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof
Address
100 Broad St.,Glens Falls,NY 12801
Death Certificate Filed District Number Regigt�r Number
City, Town or Village Queensbury 5657 [ ( (`���
❑Burial Date Cemetery or Crematory
Entombment September 29,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
I' Hold
N
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
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
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human r mains described
ove as indicated.
Date Issue i 3.2 I 1 (p Registrar of Vital Statistics Q, 11^,-...._
_ (signature)
.: District Numbers(" Place ) 0 u--+,� d4
bu,_12,..4.4,
I certify that the remains of the decedent identified above were disposed of in accor nce ith this permit on:
I— ,
Z
UJ Date of Disposition /0131i1, Place of Disposition fni\Itw 6 thrator-ia-.
W (address)
Cl)
r4 (section) /,(lot number) ( (grave number)
p Name of Sexton or Person in Charge o Premises Mot
t!
Z , (ple se print)
W Signature Title f f i WWI.
(over)
DOH-1555 (02/2004)