Provost, George NEW CORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George M. Provost Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 10, 2012 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 7 Hamilton Street
Manner of Death El Natural Cause El Accident El Homicide 0 Suicide Undetermined r7 Pending
Circumstances Investigation
Medical Certifier Name Title
Robert P Reeves, Dr.
Address
Three Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
®Burial Date Cemetery or Crematory
December 13, 2012 Pine View Cemetery
❑Entombment Address
it ❑Cremation uua cer Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held Pine View Cemetery
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterme t ! Date Cemetery Ad
Kip
Reinterment etery Address
41
Permit Issued to � Registration Number
Name of Funeral Home M.B. Ki uFF neral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
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 rema"iris scribed a ve as "ndicated,
i? Date Issued ) -) 1 a-1 l�.-- Registrar of Vital Statistics C_
fr t (signature)� District Number`-\ 5'a4 Place � CI 6 L rt. S 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/13/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Horicon 25 B 1
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Michael Genier
(please print)
Signature 91ti Title Superi nt-Pndent
(over)
DOH-1555 (02/2004)