Prouty, Jack NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
xy , Name First Middle Last Sex
Jack H. Prouty Male
`. Date of Death Age If Veteran of U.S. Armed Forces,
kg;. April 29,2017 75 War or Dates
. Place of Death Hospital, Institution or
Z; City, Town or Village Johnsburg Street Address 37 Sodom Cross Road
a Manner of Death I XI Natural Cause n Accident Homicide Suicide Undetermined Pending
W.
Circumstances Investigation
it Medical Certifier Name Title
Jennifer Donovan
`' Address
126 Ski Bowl Road,Johnsburg,NY 12843
• Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 1 3
El Burial Date Cemetery or Crematory
May 3, 2017 Pine View Crematory
El Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
u)
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
• Address
3809 Main Street,Warrensburg,NY 12885
y Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
13
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Permission is hereby granted to dispose of the human rema s descri d e as indi at-
`:::: �'�• Date Issued S —1 Registrar of Vital Statistic o
(signature)
District Number 5 4 Place T/O Johnsburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i—
j'
w Date of Disposition 511 in Place of Disposition 43ncVsw eirmu'}or
(address)
W
0 (section) //(lot number) - (grave number)
QName of Sexton or Person in Charge of Premises 74,1 1,r- J ti+yl ii-
W (plse print)
2
Signature a Title (3F-I ►'t,
(over)
DOH-1555 (02/2004)