Allen, Franklyn NEW YORK STATE DEPARTMENT OF HEAL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,Franklyn James Men Male
Date of Death Ag If Veteran of U.S. Armed Forces,
2,_ 1 '08/2018 70 YE War or Dates
Place of Death Hospital, Institution or
gCity, Town or Village Albany Street Address Hudson Park Rehabilitation And Nursing Center
ti Manner of Death airul Natural Cause ci Accident El Homicide 0 Suicide ri Undetermined El Pending
Ul """Circumstances Investigation
CI
uni Medical Certifier Name Title
lq Roman Koldayev MD
Address
,.., 325 Northern Blvd,Albany,New York 12204
" Death Certificate Filed District Number Register Number
tt,.*
, City, Town or Village Albany 0101 2726
OBurial Date Cemetery or Crematory
12/11/2018 Pine View Crematorium
DEntombment
S-iv/ Address
Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
,.1 and/or Address
Hold
Date Point of
1 0 Transportation Shipment
by Common Destination
-,-$ Carrier
El Disinterment _
Date Cemetery Address
,--:'
10,
u i—i Reinterment Date Cemetery Address
lia
,4 -
ot, Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
'. 68 Main Stpo Box 67,Hudson Falls,New York 12839
.410
.0* Name of Funeral Firm Making Disposition or to Whom
t* Remains are Shipped, If Other than Above
Address
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
4-=
:41 Date Issued 12/11/2018 Registrar of Vital Statistics Danierk S gaspie PEkctronicalry Signed:1
.00 (signature)
vo;
w District Number (not Place Albany, New York
rel,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
gDate of Disposition,1,-,--f i--'1 ' Place of Disposition P;tie, Vi e/11/ reithel-kx'Y
(address)
(section) (lot number) (grave number)
,----
Name of Sexton or Person in Charge of Premises \I efill-01 S gli,il,5
Z (pleas Vprint)
W •
Signature Title Ckiing+or
(over)
DOH-1555 (02/2004)