Prouty, David Michael ( LF )
NEW YORK STATE DEPARTMENT OF H EALTH °� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Michael Prouty Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/29/2022 62 Years War or Dates
t,. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 227 South Street,Glens Falls,New York 12801
UJ
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined riPending
W C.) Circumstances Investigation
W Medical Certifier Name Title
O Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 660
Burial Date Cemetery,Crematory or Facility Name
12/30/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 El Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
() Transportation Shipment
p by Common
Carrier Destination
111
Disinterment
Date Cemetery Address
11 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804 _
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Other than Above
a Address
CC
W
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/30/2022 Registrar of Vital Statistics Megan Horn gketronicaliy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on://
Z Date of Disposition /,.-31Z,ZZ Place of Disposition V r��' ✓rb'.4) Crr 4.4.IJJ
f-
2 (address)
W
N CC (section) (lot number/ (grave number)
CName of Sexton or Person in Cha a of P e i s i�T /11 w
Z I (please print)
W Signature Title les—r-A �" C
DOH-1555(o7/18)pi of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 <
! r'
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#