Potter, Jane Boyd NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane Boyd Potter Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/18/2021 90 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
W 0 Natural Cause ❑Accident ❑ Homicide ❑Suicide
U Circumstances Investigation
W Medical Certifier Name Title
CI Howard Silverberg MD
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 407
Burial Date Cemetery,Crematory or Facility Name
09/21/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
0
Q. Date Point of
U) 1-1
Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
5 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/21/2021 Registrar of Vital Statistics Rp6ert Andrew Curtis.gYectromi-a(S ned
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition T/ i It Place of Disposition � d=
iil
2 (address)
Lu
CC CC (section) (lot number) (grave number)
4
Name of Sexton or Person in Charge of Premises 1�� µ
Z ( ease print)
W Signature Title (041viWie
DOH-1555(07/18)p 1 of 2
0.51.54
Public Health Law Sec. 4145(2b)
Receipt ` fbn�
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#