Loading...
Potter, Lois C 4 7 3 NEW YORK STATE DEPARTMENT OF HEALTH BurTransit ial - Permit Bureau of Vital Recordsermit Name First Middle Last Sex Lois C.Potter Female Date of Death Age If Veteran of U.S.Armed Forces, 09/02/2021 91 Years War or Dates F._ Place of Death Hospital,Institution or Z City,Town or Village Hartford Town Street Address 77 Northrup Lane, Hartford Town,New York 12838 11/ p Manner of Death © Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending tL U Circumstances Investigation LU Medical Certifier Name Title 13 Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 5 Burial Date Cemetery,Crematory or Facility Name 09/03/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York 0 Donation goRemoval Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of N ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom E- Remains are Shipped,If Other than Above gY Address CC W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/03/2021 Registrar of Vital Statistics Denise cPetteys(E(ectronicalrySigned) (signature) District Number 5759 Place Hartford, 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 '-— LPlace of Disposition 1 Iw —/ZD" / P �� r1 V.��� L r � 2 (ad ress/ W N CC (section) lot number) (graven tuber) 0 Name of Sexton or Person in Charge of Premis R441,J0Ad-47 W Z / (please print) W Signature // Title DOH-1555(07/18)p 1 of 2 r I el O � ,s ..Lt ..� Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#