Allen, Cecil NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
._ Name First Middle Last Sex
Cecil Henrietta Allen Female
Date of Death Age If Veteran of U.S. Armed Forces,
Au•ust 10, 2016 102 War or Dates
I Place • 9__th Hospital, Institution or
W. City, town •r Village Queensbury Street Address 88 Boulevard
Mann- of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LLI
Circumstances Investigation
W Medical Certifier Name Title
Ci Gerald F Abess MD,
Address
3 Irongate Ctr. Glens Falls, NY 12801 _
Death ciiEt
Yicate Filed A District Number Re ter Number
City, own r Village LA,ee;IS bW'i 5(051 (�j
®Burial Date Cemetery or Crematory
August 15, 2016 WEST GLENS FALLS CEMETERY
❑Entombment Address
['Cremation Main St. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold WEST GLENS FALLS
-CO. Date Point of CEMETERY
pn Transportation Shipment
CO by Common Destination
CI Carrier
Date Cemetery Address
Li Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
Permission is hereby granted to dispose of the human rent4 d scribe o ' di ated.
Date Issued - (?--((p Registrar of Vital Statistics
(signatu
')
District Number c4 1 Place '�0 y. (-=' tag L,--j 1.E,A
4
,
I certify that the remains of the decedent identified abov ?vere disposed of in a •- - ith this permit on:
W Date of Disposition 08/15/2016 Place of Disposition ain St. Queensbu , :i
2 (address)
LU Allen Family Plot, West Glens Falls
Ct (section) (lot number) (grave number)
0 Name of Se n or Person in Charge of Pre . es Connie L. Goedert
ego UlC�
(please print)
Signature Title Cemetery Superintedent
(over)
DOH-1555 (02/2004)