Allen Jr, Cassius ZIO
NEW YORK STATE DEPARTMENT OF HEALTH .#Vital Records Section Burial - Transit Permit
fr Name First Middle Last Sex
Cassius M. Allen,Jr. Male
f: Date of Death Age If Veteran of U.S. Armed Forces,
March 16, 2016 43 War or Dates NA
: Place of Death Hospital, Institution or
City, Town or Village Town Of Lake George Street Address 2268 Route 9N,Lake George, NY
r • Manner of Death.• Natural Cause Accident Homicide X Suicide Undetermined Pending
Circumstances Investigation
. ! Medical Certifier Name Title
Michael Sikirica MD
Address
r:: 50 Broad St.Waterford,NY 12188
:.:; Death Certificate Filed District Number Register Number
_.•_.3 City, Town or Village Town of Lake George, NY
❑Burial Date Cemetery or Crematory
March 18, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
� Permission is hereb granted to dispose of the human remains described above as indicated.
: :s
Date Issued 1 Registrar of Vital Statistics De_bg4a,ii (i1 .
/ 1.� (sign ure)
r : District Number ,54P 5 i Place °O 1 Aaxe' /,i. 9dC�
I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on:
W Date of Disposition 3/ZZ IN Place of Disposition 4j Vjti ( a'ftX/0,
2 (address)
W
CO
CL (section) A (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises i 4 tss 1yv S tiar
Z ( ease print)
W
Signature 411 Title I-MAIM
(over)
DOH-1555(02/2004)