Provenzano Sr, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert P Provenzano Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/22/2015 74 years War or Dates
Plaak of Death Hospital, Institution or
ity dWtX&AXIdtaX Glens Falls Street Address Park St Glens Falls, N Y
aManner of Death r�� Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
i it Circumstances Investigation
ul Medical Certifier Name Title
Cl Daniel Way M. D.
Addres
100 Fark Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
. ty,7raWtiQk itiMAX Glens Falls 5601 314
>!: i JBurial Date Cemetery or Crematory
06/22/2015 Pine View Crematory
i ❑Entombment -
Address
Cremation Queensbury, NY
Date Place Removed
Z
❑Removal and/or Held
.... and/or Address
�= Hold
Cl)
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;'; Address
#r
in
tU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/22/2015 Registrar of Vital Statistics ufr 3 A kij
(signatu )
District Number 5601 _ Place Glens Falls, N V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
iLI Date of Disposition L,-a3-)S Place of Disposition ;ne v,'-eLt.) Cr e rvi ti a(t'0 r►n
it (address)
UI
CA
CC (section) (lot number) (grave number)
,.r
• Name of Sexton or Person in Charge of Premises j trn p.4 v r..et'/e
2 (please print)
Signature t;�.: ? e k Title (re Ima-k or7 in S5�•
(over)
DOH-1555 (02/2004)