Prutsman, Harry NEW YORK STATE DEPARTMENT OF HEALTH "
Vital Records Section Burial Transit Permit
• Name First Middle ' . Last Sex
Harry Charles Prutsman Male
▪ Date of Death Age If Veteran of U.S. Armed Forces,
• xi1 June 1,2012 69 War or dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village _ Street Address Glens Falls Hospital
Manner of Death n Natural Cause Accident n Homicide [1 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
P, Aged A.Gillani MD
Address
102 Park Street Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 2 6 Z
❑Burial Date Cemetery or Crematory
❑Entombment June 4, 2012 i Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804 _
Date Place Removed
Z C Removal and/or Held
C and/or Address
H Hold
N
0 Date Point of
O.
n Transportation Shipment
a by Common Destination
Carrier
[i Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
• Name of Funeral Firm Making Disposition or to Whom
t:9 Remains are Shipped, If Other than Above
Address
fa
Permission is hereby granted to dispose of the hum n remains escribed ove as indi :ted.
Date Issued 6 f' // a Registrar of Vital Statistics ��
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above we e disposed of in accordance with this permit on:
Date of Disposition c f y Ji1 Place of Disposition FtaUtto (,-w►. a t+A--
2 (address)
co
p0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ac,„1,14r S t vita
Z (please print)
W Signature �� Title (/ rywta
(over)
DOH-1555(02/2004)