Allen, Andrew . 1 C,
NEW YORK STATE DEPARTMENT OF HEALTH itlI 'EL.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex Male
Andrew L. Allen
i Date of Death Age If Veteran of U.S. Armed Forces,
10/18/2010 51 War or Dates
} Place of Death Hospital, Institution or
2 Ow Town o IJ Hadley I Street Address 13 1st Avenue
Manner of Death( J Natural Cause El Accident Homicide ®Suicide 0Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
;fl John DeMartino Coroner
Address
339 Northline Road Ballston Spa,New York
Death Certificate Filed District Number Register Number
ME Town • 4) .1 Hadley 1
Date Cemetery or Crematory
❑Burial j 10/22/2010 • Pine View Crematory
` Address
Cremation' Queensbury,New York
Date 1 Place Removed
Q❑Removal and/or Held
N- and/or Address
g Hold •
Q Date : Point of
N L Transportation Shipment
A by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date i Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home
Brewer Funeral Home. Inc. 00205
Address
24 Church Street, PO Box 500, Lake Luzeme,NY 12846
;'M Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the human re ins described above as indicated. ?
Date Issued JO-g/• /d Registrar of Vital Statistics Vim'- C,--/
(signature)
District Number `VS-S y Place&A...)--"PA...)--"Pt -`�WO-�►I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- /�
Date of Disposition 10 �ZZ AO Place of Disposition P,Y.I.Ole..) Cevrcior,v.`
2 (address)
ill
V)
C (section) 2 (lot number)- (grave number)
0 Name of Sexton or Person in Charge of PremisesI, I,n rs 114 r .31,4040
g (please print)
W Signature Title (17 OVA roe_
DOH-1555 (10/89) p. 1 of 2 VS-61