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Allen, Desmond Tr NEW YORK STATE DEPARTMENT OF HEALTH cq f Vital Records Section . .. . Burial - Transit Permit Name First Middle Last Sex TPsmond H. Allen Male Date of Death Age If Veteran of U.S. Armed Forces, 08/31 /201 5 1 01 yrs . War or Dates No I.. .. Place of Death Town of Hospital, Institution or Heritage Commons WCity, Town or Village Ticonderoga Street Address Residential Health Care p Manner of Death©Natural Cause El Accident El Homicide El Suicide ❑Undetermined ❑Pending IU Circumstances Investigation W Medical Certifier Name Title II Todd R. Waldorf D.O. Address 1019 Wicker Street Ticonderoga, NY 198 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 47 ❑Burial Date Cemetery or Crematory 09/04/2015 Pine View Crematory ❑Entombment Address ❑X Cremation Queensbury, New York Date Place Removed Z Removal and/or Held 9 I—Iand/or Address Hold 1/1 0 Date Point of tl3i1El Transportation Shipment 0 by Common Destination Carrier El Disinterment Date Cemetery Address . ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox & Regan funeral home 01 821 Address 11 Algonkin St. , Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above 2 Address Permission is hereby granted to dispose of the human remai e ribed abo e as i dicated. Date Issued 0 9/0 2/2 01 5 Registrar of Vital Statistics - � �� (ld� C (sig - e) District Number 1 564 Place Town of Ticond oga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1t ILI Date of Disposition i/o jig- Place of Disposition fekitk., 6 croo.., (addr ss) W Cl, C (section) A (lot number) (grave number) zName of Sexton or Person in Char a of Premisesoat g +�(pl a print- M ) • SignatureA: Title liZ,fV. (over) DOH-1 555 (02/2004)