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Provo Jr, Pearly
#(117 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Pearly J. Provo, Jr. , M Date of Death Age If Veteran of U.S.Armed Forces, 07-18-2014 77 War or Dates 1955-57 Place of Death Hospital, Institution or 5 City,Iytrllfggc Plattsburgh, NY _Street Address CVPH Medical Center Manner of Death©Natural Cause Ei Accident ID Homicide 11 Suicide nUndetermined ID Pending Circumstances Investigation iii Medical Certifier Name Title navid nonah Coroner Address €' Plattsburgh, NY 12901 Death Certificate Filed District Number Register Number City,TfiemorMlbasec Plattsburgh, NY 901 _ ❑Burial Date Cemetery or Crematory :;'::;:.[;Entombment Address07-22-2014 Pine View Crematorium Vii:'\Cremation Queensbury, _ NY _ i ri ik Date Place Removed 8: Removal and/or Held and/or Address Hold Date Point of Q Transportation Shipment _ a by Common Destination Carrier `` Disinterment Date Cemetery Address iiii Q Reinterment Date Cemetery Address .:; _ :;inii Permit Issued to -. Registration Number <€ Name of Funeral Home REgan Denny Staf ford Funeral Home '' Address 53 Quaker Rd, Queensbury, NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address ' Permission is hereby granted to dispose of the human remains describ ' ab a as indicated. Date Issued0 7-21 -2 01 4 Registrar of Vital Statistics - �� .fi/.� (sgnaturer District Number 901 Place City of Plattsburgh l I certify that the remains of the decedent identified above were disposed of in 4.../ ccordance with this permit on: Date of Disposition `l-tCI-(j Place of Disposition p... (address) Ill VI (se�cb"on) (lot number (grave number) Name of Sexton or Person ' Charge f Premises 7'a'{ 'r (ple print) Signature Title C74:41 (over) DOH-1555 (02/2004)