Prouty, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section x Burial - Transit Permit
Name First Middle Last Sex
Helen C. Prouty Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 9,2011 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 16 Monroe Street
O Manner of Death n Natural Cause n Accident I I Homicide Suicide n Undetermined Pending
W Circumstances Investigation
Medical Certifier Name Title
I.'
Address
• Death Certificate Filed ' District Number Register Number
City, Town or Village Glens Falls,NY 5601 L-I 1--)5
❑Burial Date Cemetery or Crematory
❑Entombment October 11,2011 Pine View Crematory
Address
CI Cremation Quaker Road, Queensbury,NY 12804
Date ' Place Removed
ZO n Removal and/or Held
and/or Address
--' Hold
(0
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
E
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan& Potter 01646
Address
tl 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
!* Remains are Shipped, If Other than Above
N Address
CZ
ILf
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10) i t / i try Registrar of Vital Statistics Wc{ L.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:
Z DispositionPlace of Disposition /�
W Date of Ip��lt( p Re.o�r.�w �tvY►-4}or,,,�
2 (address)
W
cn
ct (section) /'}` i (lot numb (grave number)
p0 Name of Sexton or Pers in Charge of remises L has orar
'Z (please print)
�Sinature Title
, C!�F_MAT 6 IZ
(over)
DOH-1555(02/2004)