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Peck, Allen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Allen C. Peck Male Date of Death Age If Veteran of U.S. Armed Forces, -_ August 14,2014 76 War or Dates a Place of Death Hospital, Institution or City, Town or Village CIO Glens Falls Street Address Glens Falls Hospital zi` Manner of Death X Natural Cause n Accident n Homicide Suicide n Undetermined —Pending la Circumstances Investigation [W Medical Certifier Name Title Amy Hogan-Moulton MD Address '., Two Broad Street,Glens Falls,NY 12801 Death Certificate Filed _ District Number Register Number City, Town or Village Glens Falls 5601 7) ❑Burial Date Cemetery or Crematory ❑Entombment August 18, 2014 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed ZO I Removal and/or Held and/or Address F_ Hold to 0 Date Point of a. w Transportation Shipment a by Common Destination Carrier —Disinterment Date Cemetery Address Li Reinterment Date Cemetery Address ', Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 1s 3809 Main Street,Warrensburg,NY 12885 =F=w Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address x Ei Permission is hereby granted to dispose of the human remains described above as indicated. : Date Issued 3 I i c j .©tLI Registrar of Vital Statistics U1/4.)cuk.,v-,...Q., JJ 'Al(signet ) District Number 5601 Place Glens Falls f/��" /,),D f I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LU Date of Disposition v(tOIN Place of Disposition ?iota., G` � W (address) co 0 (section) (lot num r Z _1)" (grave number) Name of Sexton or Person in Charge of Premises ,. h LU (Tease print) Signature -,‘Z Title 04 4$l (over) DOH-1555(02/2004)