Wood Jr, Allen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
;: ! Name First Middle Last Sex
", Allen E. Wood,Jr. Male
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V Date of Death Age If Veteran of U.S. Armed Forces,
August 5,v,. 2016 68 War or Dates Vietnam
�` Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident Homicide [1 Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski
Address
100 Park Street,Warrensburg,NY 12885
Death Certificate Filed District Number Z Reg �f�yq�ber
%. City, Town or Village l}v
❑Burial Date Cemetery or Crematory
❑Entombment August 8, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
E Hold
N
O Date Point of -
N0 Transportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
i; ! Permit Issued to Registration Number
"'` Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
' Address
' f' 407 Bay Road,Queensbury, NY 12804
; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r r Permission is her by granted to dispose of the human remains descr' e a ov s i ed.
� ` /
; Date Issued ("8"d 1.201b Registrar of Vital Statistics
r-` � � .(signature)
. ,; District Number J(�0� Place
I certify that the remains of the decedent identified above were disposed of in accordance/ with this permit on:
Z / 'fU
Date of Disposition $ l in, Place of Disposition a,,,
ill (address)
N
0 (section) pot number) (grave number)
p Name of Sexton or Person in Charge of Premises ���r(�L S�.Ot
Z (pIIse print)
W (-�'` Wag-
Signature Title
(over)
DOH-1555(02/2004)