Potter, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
," „ Name First Middle Last Sex
''j Mary Ann Potter Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 September 12,2013 85 War or Dates No
%f Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death C Natural Cause Accident Homicide n Suicide Undetermined n Pending
Circumstances Investigation
V. Medical Certifier Name Title
I David Slingerland
Address
a 100 Park Street,Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
Y f'
❑Burial Date Cemetery or Crematory
El Entombment September 13,2013 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO C Removal and/or Held
and/or Address
F" Hold
N
O Date Point of
N []Transportation Shipment
'p by Common Destination
_ Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
f;
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
iRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 P3 it 3 Registrar of Vital Statistics L -°L1-/"\-/Z
(signature)
f
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance' with this permit on:
W Date of Disposition 1t13113 Place of Disposition Zia v eK ,c4Of14.--
W (address)
N
lY (section) (lot num (grave number)
QName of Sexton or Person i r harge of Pre ises aI . /r 4i
Z '� (please print)
ut
Signature fib, Title Oftv*TOIC
i
(over)
DOH-1555(02/2004)