Provost, George NEW YORK STATE DEPARTMENT OF HEALTH , 517
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,
November 14,2011 83 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
C1 Marvin Davidoukz Dr.
Address
100 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
El Entombment Address
17,2011 Pine View Cremato _
Address
LI Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO -
O Date Point of
NTransportation 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 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
t- Remains are Shipped, If Other than Above
g Address
C
W --
Permission is hereby granted to dispose of the human remains described above as pdicated.
Date Issued 11-16-11 Registrar of Vital Statistics (JJ,.A-^'
(signature)"
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Nod ri Place of Disposition 90411,0 (,c1+..c f pt tw
(address)
(section) , (lot number) (grave number)
pName of Sexton or Person in C rge of Premises �nyt r S444
Z ( ase print)
Signature Title C12EA4{1-
(over)
DOH-1555 (02/2004)
�-. -- uE uC - L LTL rye uVC - -- ---- - -
1
(over)
DOH-1555 (02/2004)