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Prevost, Adam C
. , '-zv NEW YORKSTATE DEPARTMENT OF HEALTH L. Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Adam C. Prevost Male Date of Death Age If Veteran of U.S.Armed Forces, 04/07/2023 38 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital W p Manner of Death ❑Natural Cause Accident Homicide ❑Suicide ❑Undetermined ❑Pending 111 X U Circumstances Investigation W Medical Certifier Name Title Cl Blake Nourie MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed City Of Albany District Number Register Number City,Town or Village 0101 0846 EBurial Date Cemetery,Crematory or Facility Name 04/08/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held F— Hold Address N 0 Q. Date Point of t/)ETransportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment Ei Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/07/2023 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed) (signature) District Number 0101 Place City Of Albany I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I 7 ,(7 Z Date of Disposition II 1I0/7. Place of Disposition t,,,,,4/_ -p-- . W 2 (address) W CCCC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises are 14 Z (phase print) Z W Signature i' Title ` �'�'�� DOH-1555(07/18)p 1 of 2 ' Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 11(&-'\ Town of Queensbury Certification of Cremation Pine View Cemetery and Crematory This certifies that the remains of: Adam C Prevost were cremated on April 10 20 23 at the Pine View (Month) (Day) Crematorium, Queensbury,New York, and these are the cremated remains of said body. Date of Death April 7 20 23 Age 38 (Month) (Day) Funeral Home Brewer Funeral Home Registered No. 320 (Authorized Signature) WILLS * Lot No. 60 Address RD 3 Box 3293-1 Lake George, NY 12845 Section No. B Owner Erwin Wills Plot Mohican Date 2/8/91 Approx. 100 Superficial ft. @ Location Bounded on North by Vacant, South by Vacant, East by Knickerbocker & Volk, West by Vacant. Corner Posts Remarks Deed No. (and changes) 2336 Payment Record Paid in Full 2/8/91 Record of Interments ,— - 4-- ANiCY‘ r ,xs..--k- i4.\--Q-D c)t- ' - 2 Marie M. Wills 4/15/91 ts:43 24 Arthur ERwin Wills 11 /4/2017 (Crem)11 " # 5 (-- "Al 5 1 1-- 7 I 8 'ick(-7,-/t-idekt.--7?,6‘h)//s-' ,- , - - , _ : / . i' ' /(---- 1 I '--- ,7, A'' - " I e " --,-( /' - , / I 1 s? C-') , / , < // '' ' - / )1 I/ , / / , __ /..-,_,,- / i%) //'2(7_,._ , , - / ' - ))/ 1 /-fr '''. r 5P3 -509- Fonn 144,1(94 i,14 (in/ T_ /,' t i' fir-it), ._- A,/ ,--i, yi,-- noppononoomm., PREVOST NAME Adam Prevost Ic_Fs) Age: Lot Owner: Erwin Wills Lot# Mohican 60B Grave#1 Case: Urn Died: Interred: 4 . 1 2.2 3 Funeral Home: Miller/ Brewer Cemetery: Pine View