Prouty, Murray v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Murray G. Prouty Mal
Date of Death Age If Veteran of U.S. Armed Forces,
February 17,2011 86 War or Dates Navy WWII
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death El Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
U Circumstances Investigation
w Medical Certifier Name Title
Gamal G. Khalifa MD
Address
100 Parl St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601
hiii['Burial Date Cemetery or Crematory
2/22/11 Pine View Crematorium
['Entombment Address
;Cremation Quaker Rd. Queensbury Ny
Date Place Removed
Z❑Removal and/or Held
and/or Address
F_- Hold
U)
Date Point of
t
Transportation Shipment
G by Common Destination
gl Carrier
El Disinterment Date Cemetery Address
Mil ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Sullivan-Minahan & Potter 01675
Address
407 Bay Rd. Queensbury,NY 12804
ii Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
;' Address
tt
fl` Permission is hereby granted to dispose of the human remains describe a ov as dic {L
Date Issued Registrar of Vital Statistics r' v
(signature)
giiii District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IDate of Disposition re 0. 2t4 /at i Place of Disposition ?fat V i t•..i Ovvi-<j a r r id*►-
2 ti (address)
Lu
CC (section) /I _ (lot numb (grave number)
0 Name of Sexton or Person in Charge f Premises L 1^rs;tvOIVr "tt(I-
�� � _, 1 (please print)
Signature Title Mt thr90�.
(over)
DOH-1555 (02/2004)