Potter, Sarah E :W YORK STATE DEPARTMENT OF HEALTHF Burial - Transit Permit
ireau of Vital Records
Name First Middle Last Sex
Sarah E Potter Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/11/2023 57 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village North Hudson Town Street Address 3857 US Route 9,North Hudson Town,New York 12855
Manner of Death I I Natural Cause []Accident El Homicide Suicide EIUndetermined []Pending
Circumstances / !Investigation
Medical Certifier Name Title
Ageel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of North Hudson District Number Register Number
City,Town or Village 1561 03-23
EBurial Date Cemetery,Crematory or Facility Name
12/12/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
0 Donation
EIRemoval Date Place Removed
and/or and/or Held
Hold Address
Date Point of
Transportation Shipment
by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2023 Registrar of Vital Statistics MarthaM Yang(EYectron cal 6'Signma)
(signature)
District Number 1561 Place Town Of North Hudson
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /
Date of Disposition l Z-/Z-67Z 3 Place of Disposition 7 iJ e tite,A) L 1`erri 44-0 l`�
(address)
(section) (tot numbbeyr.)� (grave number)
Name of Sexton or Person in Charge o remise '?i4 f'H10e/b LJC
`� ._(,,,(please print)
Signature %dam" / Title 0re 'e f
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#