Potter, Tammara !' f
Z.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tammara Lynn Potter Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 5, 2015 44 War or Dates
I�+:; Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ii Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
MediThç .CertifieName ,.
Title
Stckiut , Iu )
ssG,L 4- s CZ i
.r:: Death Certificate Filed 1 District Number Register Num er
City, Town or Village Glens Falls,NY 5601 Li 3 A
❑Burial Date Cemetery or Crematory
September 10, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date ! Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
N
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
•.�
.:.r Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker 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 described above.as indicated.
Date Issued 9 Registrar of Vital Statistics Q-Ai1/4-losv•Q kj3-A-^9+V4
(signature)
"f' District Number CJ 6c,1 Place G 5 C-CA 11 5 r iv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Mohr Place of Disposition r,,,.w. Cr-ik,w..
(address)
W
to
0 (section) (lot num ) (grave number)
QName of Sexton or Person in Charge of Premises /1I; � .t�
wZ dit-
(please print)
Signature ,,es.--P-- Title O KM
(over)
DOH-1555(02/2004)