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Allen Jeffrey R. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey R.Allen Male Date of Death Age If Veteran of U.S.Armed Forces, 03/24/2020 61 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Warrensburg Town Street Address 353 Schroon River Road,Warrensburg Town,New York 12885 w Manner of Death Undetermined Pending 0 ©Natural Cause Accident ❑Homicide Suicide g W Circumstances Investigation W Medical Certifier Name Title Bryan Smead MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Warrensburg 5660 6 ❑Burial Date Cemetery,Crematory or Facility Name 03/25/2020 Pine View Crematory Entombment Address iCremation Queensbury Town, New York ❑Donation ZO Removal Date Place Removed and/or and/or Held ~ Hold Address N a Date Point of to ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address 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 orto Whom F.. Remains are Shipped,If Otherthan Above a Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/24/2020 Registrar of Vital Statistics Pamela M Lloyd(Electronically Signed) (signature) District Number 5660 Place Warrensburg, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3 Zf?odh Place of Disposition �/� 4 Uj (address) W N (section) (lot number) (grave number) G Name of Sexton or Person in Ch ge of Pre s OiJ (please print/Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 134 6 3 j Receipt Human remains of -' �`,' 1 � + delivered on , 20 f 1 Pine`View r emetery+ Representing tfie funeral home named on burial permit Official Funeral Directors Reg.or License# i I I i i