Potvin Jr, Richard f
NEW YORK STATE DEPARTMENT OF HEALTH 13]
Vital Records Section Burial - Transit Permit
iiiii Name First Middle Last Sex
r:°: Richard P. Potvin,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
r::: February 28, 2014 48 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
11 Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
g Medical Certifier Name Title
41 J. Stratton Dr.
Address
:::;: 14 Manor Dr.,Queensbury,NY 12804
iii Death Certificate Filed District Numbe 0 Registef�umber
City, Town or Village Glens Falls ho'` 7
❑Burial Date Cemetery or Crematory
March 3, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
U)
O Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. r Permit Issued to Registration Number
iiiii Name of Funeral Home Regan& Denny Funeral Home 01444
iiiii Address
: ; 94 Saratoga Avenue, South Glens Falls,NY 12803
;r: Name of Funeral Firm Making Disposition or to Whom
l~+ Remains are Shipped, If Other than Above
2 Address
Permission is he e y granted to dispose of the human remains des ribe abo e a icated.
Date Issued J Registrar of Vital Statistics /I
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
W Date of Disposition 3)y by Place of Disposition Rruatui (,►••4ur�—
2 (address)
W
co
ce (section) (lot numb ) (grave number)
Q Name of Sexton or Person in Charge o Premises /ns . ph.,it
Z (please print)
W
Signature /71_ Title Cri1ENt
(over)
DOH-1555(02/2004)