Allen, Diane NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.:: Name First Middle Last Sex
Diane L. Allen Female
i Date of Death Age + If Veteran of U.S. Armed Forces,
December 1 , 2016 70 1 War or Dates n/a
Place of Death I Hospital, Institution or ,
City, Town or Village pay I Street Address 84 Bovee Road
:. Manner of Death,J Natural Cause El Accident El Homicide El Suicide ElUndetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
fl Amy Johnson RPA-C
Address
Evergreen Health Center, Corinth, NY
Death Certificate Filed I District Number Register Number
City. Town or Village Day I 4554
Date ' Cemetery or Crematory
El Burial j 12/2/2016 Pine View Crematory
Address
X Cremation! Quaker Road, Queensbury, NY
Date Place Removed
Q❑Removal and/or Held
�%- and/or Address
ig Hold
0 ' Date ' Point of
y,0 Transportation Shipment
GZ by Common Destination
Carrier
0 Disinterment I Date Cemetery Address
Reinterment Date 1 Cemetery Address
Permit Issued to Registration Number
'` Name of Funeral Home Brewer Funeral Home 00211
Address
24 Church Street, Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
IZI Remains are Shipped, If Other than Above _
laAddress
u
Permission is hereby granted to dispose of the huma main de 'bed e as indicated.
Date Issued Registrar of Vital Statistics __, -
,, \ (sign ure)
District Number" � ) Place 1 .cf ....SN'N es=t1
I certify that the remains of the decedent identified above were disposed of i ccordance with this permit on:
la Date of Dis osition la Date I21 b lit., Place of Disposition erp N) 111/Yoqi0rN".
2 (address)
iN
(I)
CC (section) ,(lot number) (grave number)
0 Name of Sexton or Person in Charge of Pre/ ises !r rr' J1i4 rt
Z (please print)
W Signature . J/ Title (RE MU--
DOH-1555 (10/89) p. 1 of 2 VS-61