Allen, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
3 Name First Middle Last Sex
Jeffrey L. Allen Male
z Date of Death Age If Veteran of U.S. Armed Forces,
January 21,2016 54 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 2434 Garnet Lake Road
0: Manner of Death X Natural Cause Accident I ]Homicide Suicide Undetermined Pending
gim Circumstances Investigation
:w Medical Certifier Name Title
John Stoutenberg
Address
102 Park Street,Glens Falls,NY 12801
. Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
January 22,2016 Pine View Crematory
❑Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
_'' Name of Funeral Home Alexander-Baker Funeral Home 00037
-' Address
' , 3809 Main Street,Warrensburg,NY 12885
r 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 human ains descri ed above as indicated.
`' Date Issued ) - "DQ-QUVegistrar of Vital Statistics n 0
(sign e)
District Number 5 JJ Place 1 �` �--� e �c� •
I certify that the remains of the decedent identified above were disposed of in accordance this permit on:
W Date of Disposition p
p /�?b /h Place of Disposition 764 1,,� t ermaton;,-'
Ill
(address)
CO
re (section) (lot numbe (grave number)
Q Name of Sexton or Person in Charge o Premises grn 3 Prat
Z ( lease print)
W Signature (a thl" Title ( ` t
(over)
DOH-1555 (02/2004)