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Potvin, Norma Ann NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Norma Ann Potvin Female Date of Death Age If Veteran of U.S.Armed Forces, 02/05/2021 86 Years War or Dates i. Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 31 Walker Lane,Queensbury Town,New York 12804 ILI p• Manner of Death ©Natural Cause El Accident ❑Homicide El SuicideUndetermined Pending Circumstances Investigation W Medical Certifier Name Title O Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 42 ▪Burial Date Cemetery,Crematory or Facility Name 02/09/2021 Pine View Cremation ElEntombment Address X❑Cremation Queensbury Town,New York Donation 6 Removal Date Place Removed and/or and/or Held H Hold Address 0 - d Date Point of U) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2021 Registrar of Vital Statistics Caroline?-i(degarieBarber(ECectronicaltySigned) (signature/ District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i- �Z Date of Disposition ��`►(7( Place of Disposition `1 '"`LLI (address) W CC (section) (lot n /er/ (grave number) • Name of Sexton or Person in Charge of Pre 'ses `/t'`i 1.OV (please print/ W Signature Title ` i� DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 01 4 5 3 U Receipt Human remains of delivered on , 20 -' Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#