Potter, Jesse James F. lici 1
TMENTOFHETH (iuI� _
Bureau of Vital Records Burial Transit Permit
Name First Middle Last Sex
Jesse James Potter Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/26/2022 42 Years War or Dates
1 Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Di Manner of Death ❑X Natural Cause Accident El Homicide Suicide Undetermined Pending
W Circumstances Investigation
{J Medical Certifier Name Title
a Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 593
Burial Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
,x ❑Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
0
IL Date Point of
/) Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
tRemains are Shipped,If Other than Above
Z Address
It
111
t , Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 Registrar of Vital Statistics Megan North(ECectronica1Ty Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
Date of Disposition f Z J Z I 7 L Place of Disposition 1��.. /+- d/'�,
2 (address)
W
In (section) 1 Ilotnumber) (grave number)
Name of Sexton or Person in Charge of Pre ises A,. i" t tf
6 / (lease"print) /
Signature
Title C It MO f (
DOH-1555(07/18)p i of 2
r
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#