Potvin, Marilyn Lois ‘307
ONEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
immovir
Name First Middle Last Sex
Marilyn Lois Potvin Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/08/2022 92 Years War or Dates }} ,
Place of Death Hospital,Insti4 ifion or
Z City,Town or Village South Glens Falls Village Street Address 47 Harrison Avenue 211,South Glens Falls Village,New York 12803
W▪ Manner of Death Undetermined Pending
[]Natural Cause []Accident []Homicide []Suicide []
Circumstances Investigation
W Medical Certifier Name Title
Aimee Mcmaster Nurse Practitioner,Acute Care
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City.Town or Village 4524 9
Burial Date Cemetery,Crematory or Facility Name
:„ 10/11/2022 Pine View Crematorium
[]Entombment Address
[]Cremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
- and/or and/or Held
- Hold Address
N
0
a Date Point of
Cl)[]Transportation
by Common Shipnif nt
Carrier Destination
Date Cemetery Address
[]Disinterment
[]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
Remains are Shipped,If Other than Above
Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2022 Registrar of Vital Statistics Samantha(Berg(ECectronicaliy Signed)
(signature)
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ,i01it 12Z Place of Disposition .t,w[L L
2 /dddress)
W
fA
Q (section) //Jr, llo.number /grave number/
Name of Sexton or Person in Charge of mises �'��
//ase print)
W Signature Title l06A714
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ` delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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