Allen, Brian NEW YORK STATE DEPARTMENT OF HEALTH R cl
S°
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Brian K. Allen Male
„ Date of Death Age If Veteran of U.S. Armed Forces,
July 20, 2016 50 .War or Dates
ta,wPlace of Death Hospital, Institution or
' City Town or Village Fort Edward Street Address 12 Bridge Street
Manner of Death ElNatural Cause ❑ Accideni 1 Homicide Suicide riUndetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Lemieux,
Address
219 Pope Hill Road Argyle, NY 12809
Death Certificate Filed District Number'rug Register Nuer
City, Town or Village Fort Edward J
❑Burial Date Cemetery or Crematory
July 21, 2016 Pine View Crematory
Ac.1=1 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/o`r Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
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 hums r ins describe ab a as ' dicated.
Date Issued I�V_)[O Registrar of Vital Statistics Auttt
(signature)
District Number�� 5 Place I � (,I�C(/((/�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/21/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section)section (lot numbe ,r (grave number)
', Name of Sexton or Person in Charge of Premises
✓" t h
please print)
Signature a ,i,...1, Title m���
(over)
DOH-1555 (02/2004)