Potvin, John NEW YORK STATE DEPARTMENT OF HEALTH ihfe
Vital Records Section Burial - Transit Permit
Name First Middle L t Sex
John P Potvin Male
Date of Death A e If Veteran of U.S. Armed Forces,
08/08/2015 Q 6-years War or Dates 1952-54
of Death Hospital, Institution or
W Cit NO% %WV Glens Falls Street Address Park St Glens Falls, N Y
anner of Death ,`'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
ui Medical Certifier Name Title
B Fred P. Scialabba M. D.
Addr ss
4t4 Glen Street Glens Falls, Ny 12801
. • h Certificate Filed District Number Register Number
liNeiciroX Glens Falls 5601 393
0-Burial Date Cemetery or Crematory
08/10/2015 l Pine View Cemetery
❑Entombment Address
'Cremation Queensbury, NY 12804
Date • Place Removed
Z Removal and/or Held
t ❑and/or
Address�,
CA
Hold
0 Date Point of
ti El Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway Fort Edward, N Y 12828
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z. Address
tr.
lLI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/10/2015 Registrar of Vital Statistics 1/0C .
(sign re)
011 District Number 5601 Place Glens Falls ,4jy /02 j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
IF-
ILI Date of Disposition 431tL(t7 Place of Disposition itp,Ati{i¢.r Ce.-A Xtw,."
2 (address)
CC (section) j (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ��' S�ovtir
� (please print)
G"a�
Signature �r Title MEAltgit
(over)
DOH-1555 (02/2004)