Allen, Virginia NEW YORK STATE DEPARTMENT OF HEALTH w : , , 3-IS
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia M. Allen Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 13,2016 87 War or Dates
; . Place of Death Hospital, Institution or
,Z City, Town or Village Lake George Street Address 120 Flat Rock Road
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
CU Circumstances Investigation
tu Medical Certifier Name Title
G Jennifer Stratton
Address
;; Queensbury Family Health Center,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Lake George 5651
❑Burial Date Cemetery or Crematory
May 17,2016 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I' Hold
CO
O Date Point of
Nn Transportation 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
Name of Funeral Firm Making Disposition or to Whom
i." Remains are Shipped, If Other than Above
a Address
AB
A` Permission is hereby granted to dispose of the human remains des ibed above as indicated.
Date Issued / /Lc Registrar of Vital Statistics t1� C rj y)/1 a it C J i i st 1,
(signature)
District Number K i Place i( k (4 f h f
l c.
I certify that the remains of the decedent identified above werldisp6sed of in accordance with this permit on:
I-
Z
W Date of Disposition 5/7o f/b Place of Disposition .,,,I, I/ (vi-e't.o�
2 (address)
W
CO
CL (section) gm(letinumb.S
(grave number)
pName of Sexton or Person in Charge of Premises
' r Z (phase print)
Signature lei -i Title ((Z tQ4
(over)
DOH-1555 (02/2004)