Allen Sr., Terry Wayne _ #
NEW YORKSTATE DEPARTMENT OF HEALTH III�' � .. Burial - Transit Permit Bureau of Vital Records
Name First Middle Last $ex
Ter Wayne Allen Sr. Male
Date of Death Age 7TIf Veteran of U.S.Armed Forces,
05/11/2020 72 YearsWar or Dates
ZPlace of Death Hospital,Institution or
W City,Town or Village Fort Ann Town Street Address 745 Deweys Bridge Road,Fort Ann Town,New York 12827
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W
C.) Circumstances Investigation
QW Medical Certifier Name Title
Mary Stein Np
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Fort Ann 1 5754 10
Burial Date Cemetery,Crematory or Facility Name
05/12/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
0 and/or and/or Held
N Hold Address
O
o- Date Point of _.
UN Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 701130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition orto Whom
Remains are Shipped,If Other than Above
;i Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/13/2020 Registrar of Vital Statistics Bar$ara,74f'nclrell-(EkctmnicaQ Srgned)
(signature)
District Number 5754 Place Fort Ann, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition sl Zb Place of Disposition --�1
X. (address)
W
N (sedion) (lot number) (grave number/
8 Name of Sexton or Person in Charge remises 1 ?
Z (plea print)
W
Signature 21111 Title /h
DOH-1555(07/18)p 1 of 2
aft -�
Public Health Law Sec. 4145(2b) 013804
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#