Potter, John NEW YORK STATE DEPARTMENT OF HEALTH 4 5-3
Vital Records Section Burial - Transit Permit
.
Name First Middle Last Sex
,
John Edwin Potter Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 7, 2012 76 War or Dates After 1/31/55
Place of Death Hospital, Institution or
{L' City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC.
W' Manner of Death ,LurcriNatural Cause EllAccident ❑Homicide ❑ Suicide n Undetermined ❑ Pending
Ci Circumstances Investigation
W Medical Certifier Name Title
a E d k }- ✓V1ct Sic,lY ,v1'1
Addre n
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Death Certificate Filed ( V District Number Register Number
City, Town or Village 5 75)
❑Burial Date Cemetery or Crematory
October 9, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑
Removal and/or Held
0; and/or Address
E
Hold
16 Date Point of
10
❑Transportation Shipment
by Common Destination
,' Carrier
❑ Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
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 mains describ d ove as indicated.
Registrar of Vital Statistics 21
Date Issued �(�1� �a` 9 r , .tA
(signature)
District Number5r-Q Place //91 p
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition lolrz hi. Place of Disposition ZV ii4j �n0'n(tOri,..--
Z°, (address)
CO
te (section) (lot number) c (grave number)
0' Name of Sexton or P rson in Char of Premises ��'�� S�"�l�
Z ( lease print)
W Signature , L .,��sr/2
Title C .
(over)
DOH-1555 (02/2004)