Allen, Frederick f l !► 110
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frederick C.Allen Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/25/2017 81 Years War or Dates 1956-1959
Place of Death Hospital, Institution or
Y'< City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause ❑Accident Homicide ❑Suicide Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Miles MD
fi i Address
• 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 605
❑Burial Date Cemetery or Crematory
11/27/2017 Pineview
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
• Carrier
4-4❑Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
art.
Date Issued 11/27/2017 Registrar of Vital Statistics ,6ertAcurtis cEfectronica1Zysignee
(signature)
te District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1/ hefill Place of Disposition .1;,4; „_, (^""e4 a•.•
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises fir..
(p1 sse print)
or Signature ✓ l Title (ON Pir,
(over)
DOH-1555 (02/2004)