Potter, Joyce # 300
NEW YORK STATE DEPARTMENT OF HEALTH r� ```"'
Vital Records Section Burial - Transit Permit
a. Name First Middle Last Sex
e. Joyce Potter Female
}jr Date of Death Age If Veteran of U.S. Armed Forces,
I~�P April 19, 2015 83 War or Dates
" Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
iMariner of Death I XI Natural Cause Accident l I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
;,., Roslyn Socolof
Address
r. Westmount Health Facility,Queensbury,NY 12804
: : Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 `Q
❑Burial Date Cemetery or Crematory
CI Entombment April 21, 2015 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
h" Hold
Cl)
0 Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
444 Permit Issued to Registration Number
V Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
:; 407 Bay Road, Queensbury, NY 12804
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 describeddlabov as indicated.
{: l
���� Date Issuedla{ aol, Registrar of Vital Statistics Cie ft�,
:
(signature)
.E:;s District Number 5657 Place Queensbury
L:.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition N'Nip' Place of Disposition 4t,w,0,,,,/ `r.�,:te.;,�,
2 (address)
W
Cl)
Ce (section) �°t number) (grave number)
Q Name of Sexton or Person in Charge of Premises I 'r• 1,-PN-
Z (ple se print)
W Signature Title !'it(;n1
(over)
DOH-1555(02/2004)