Stern, Allan NEW YORK STATE DEPARTMENT OF HEALTH 1 J zn
Vital Records SectionkookBurial - Transit Permit
:r;, Name First Middle Last Sex
'ri: Allan Richard Stern Male
';'rj Date of Death Age If Veteranof17.S. Armed Forces,
mJuly 24, 2016 59 War or Dates
= Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
hte Manner of Death n n E Undetermined Pending
Natural Cause Accident Homicide Suicide
Circumstances Investigation
. Medical Certifier Name Title
. Dr Bain,MD
tr 1 Address
:j Glens Falls,NY
•:'-' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
July 25, 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration r 9�stration Number
:•
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
r':ti 53 Quaker Road,Queensbury,NY 12804
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
1
Date Issued 2) �--5 I /t Registrar of Vital Statistics 1../QQA-kyry-‘4
Si: (signature)
District Number 5 60 ( Place City of Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 7/24/11, Place of Disposition itt(4)Ms, [ 'dr+..,-
W (address)
CO
W (section) /1i (lot number)cc (grave number)
pName of Sexton or Person in Charge of Premises G rr1 �)c»�41
`LI
Z //� lease print)
Signature C 7a- Title OW/WO-
(over)
DOH-1555(02/2004)