Allen, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH 42./
Vital Records Section 4 • Burial - Transit Permit
Name First Middle Last I Sex
Dorothy A. Allen ; Female _
Date of Death Age I If Veteran of U.S. Armed Forces,
April 23,2011 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
tu
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
b3' Circumstances Investigation
: Medical Certifier Name Title
P., Dr North,MD
Address
Glens Falls,NY
Death Certificate Filed District Number j Regis t7Amber
City, Town or Village Glens Falls,NY 5601 1
❑Burial Date Cemetery or Crematory
April 25, 2011 I Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbur , NY 12801
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date i Point of
NTransportation Shipment
a by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to I Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury, NY 12804
s, Name of Funeral Firm Making Disposition or to Whom
>M; Remains are Shipped, If Other than Above
N: Address
IX:
Permission is her by granted to dispose of the human remains described bove as indic. ed.
Date Issued 5 Registrar of Vital Statistics U�— ,--) 0'
si nature)
�• ,; District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above w e disposed of in accordance with this permit on:
WDate of Disposition Li— a tm - t( Place of Disposition ? n e u k`.ew) Cee yri gi„__-41r.:om
W (address)
Cl)
CL
(section) (lot number) (grave number)
pName of Sexton or Person in Char of Premises ` 1T 1,A-i, ��j,r,,r,,//.
Z (please print)
W
Signature e,,i,,,., Title Cr -te or s -
(over)
DOH-1555(02/2004)