Allen, Joan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
q.i, Name First Middle Last Sex Female
O Joan M. Allen
a
Date of Death Age If Veteran of U.S. Armed Forces,
s; 5/24/2011 [ 69 War or Dates no
Place of Death Hospital, Institution or
City.XMOTcraNN Saratoga Springs Street Address Saratoga Hospital
Manner of Death' Natural Cause ❑Accident El Homicide ❑Suicide 0 Undetermined Q Pending
Circumstances Investigation
Medical Certifier , . ame U Ti
)g,
, un,(1,-L to( ci/t. Mn
r,.e Addre
Death Certificate Filed Distr�Number R ister Number
ry.
rl
City, D e Saratoga Springs 4501
Date Cemetery or Crematory
: : ❑Burial 5/25/2011 Pine View Crematory
Address
n Cremation Queensbury,NY
Date Place Removed
?❑Removal I and/or Held
tt and/or = Address
Hold
0 Date T Point of
(fit,}0 Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
__ 4 Permit issued to Registration Number
v"k:< Name of Funeral Home Brewer Funeral Home, Inc. 00205
:-, Address
!!{> 24 Church St., Lake Luzerne,NY 12846
`'`' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
itl
G"`u Permission is hereby granted to dispose of the human remains d ed ov in 'sated.14- Date issueck5 1?J/20 t ' Registrar of Vital Statistics 1 -
(signature)
`, District Number Liao` Place C-i 1 c �ccc �� 4r�ls , NY
,�s
?: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Dirt Date of Disposition S Z7--i( Place of Disposition fit drri Ct tr,<tl(),r-
(address)
A
(section) a
(lot umber) - (grave number)
Name of Sexton or Pers n in Charge o' remises r+ J �+`t�
L- (please print)
4 Signature Title C R. 61.-
DOH-1555 (10/89) p. 1 of 2 VS-61