Prefountaine, Farrell NEW YORK STATE DEPARTMENT OF HEALTH . r •
Vital Records Section Burial - raflSlt Permit
Name First Middle Last Sex
Farrell Prefountaine Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. October 17, 2016 73 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death ❑x Natural Cause El Accident ❑Homicide El Suicide 0 Undetermined El Pending
W Circumstances Investigation
Medical Certifier Asim thaudy MD
W
Q Address
102 Park Street Glens Falls New york 12801
Death Certificate Filed District Number Register Number 530
City,Town or Village Glens Falls &COO i
Date Cemeteryor Crematory
❑Entombment Address
®Cremation Pine View Crematorium ,Town of Queensbury
Date Place Removed
4 0 Removal and/or Held
and/or Address
Hold
0 Date Point of
0 El Transportation Shipment
d by Common Destination
Carrier
0 Date Cemetery Address
aEl Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is hereby granted to dispose of the human remains d cribed above as indica
Date Issued /0/� pjlp Registrar of Vital Statistics ,) L ` --!>
(signature) ��
District Numbers/ Place Glens Falls,New Yo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 �
W Date of Disposition %oi t( ilk Place of Disposition e...iVa./ Cr~to f s,....„
2 (address)
Id
td
0 (section) Jlot number) (grave number)
2 Name of Sexton or Person in Charge of Premises 6(0 r/yi(,� 3t a q f It
2 (pease print)
Signature et y,.tv- Title ni aitPt
(over)
DOH-1555 (02/2004)