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DeLong, Allan NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit ermit Name First Middle Last Sex Allan L. DeLong Male Date of Death Age If Veteran of U.S. Armed Forces, September 5,2011 64 War or Dates I Place of Death Hospital, Institution or City, Town or Village Warrensburg Street Address 24 Third Avenue fl Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending Ai Circumstances Investigation w Medical Certifier Name Title O Robert W. Sponzo Address 102 Park St.,Glens Falls,NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Warrensburg 5660 /S ❑Burial Date Cemetery or Crematory September 7,2011 Pine View Crematory DEntombment Address ©Cremation Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held 52 and/or Address H Hold O Date ' Point of NTransportation Shipment p by Common Destination Carrier _ Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom }. Remains are Shipped, If Other than Above 2 Address CL ,tit Permission is hereby ranted to dispose of the human • 1 = .escribe above as indicated. Date Issued Cl/ Registrar of Vital Stati i ,47,72 , ‘ni i (signature) District Number 5660 Place Warrensburg I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on: w Date of Disposition 4 A((i Place of Disposition e L,noVW, ia..'�IIK,- W (address) N O (section) , (lot number (grave number) pName of Sexton or Perso in Charge Premises Ac►1{ 1 N— Z (please print) W Signature I Title CQtiI' cdv_ Q (over) DOH-1555 (02/2004)