Allen, Judith NEW YORK STATE DEPARTMENT OF HEALTH z- *► It (o S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Judith Marie Allen Female
Date of Death Age If Veteran of U.S. Armed Forces,
2/1 9/1 2 7 0 War or Dates No
Place of Death Hospital, Institution or4
City, Town or Village G e n s Fall s Street Address 4— �_ tp= �St. C e.A.JC .-'�
Manner of Death n
brj Natural Cause ❑Accident ElHomicide ElSuicide El❑Undetermined ❑Pending
ILI Circumstances Investigation
tg Medical Certifier Name Title
3 Paul R. Filion MD
Address
Irongate Center, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 -26 \--
❑Burial Date Cemetery or Crematory
❑Entombment 2/21 /1 2 pine View Crematory
Address
Cremation Quaker Road, Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
5 Hold
O Date Point of
Transportation Shipment
G� by Common Destination
Carrier
M ElDisinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. KIlmer Funeral Home 01 078
Address
136 Main St. So. Glens Falls, NY 12803 ,
Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped, If Other than Above
Address
Lu
Permission is hereby granted to dispose of the human remains described abov as' i ated.
>> Date Issued 2/21 /1 2 Registrar of Vital Statistics ./ 'b rsy
(signature)
District Number 5601 Place Glens Falls, NY
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1,4
ILI Date of Disposition Felt, Ili ?xi?. Place of Disposition ,mV �,n,,,c'vr,.,,
(address)
iSi
fil
CC (section) dr (lot number) (grave number)
ci Name of Sexton or Per on inCharge f Premises ,st L^ biak
(please print)
41
Signature Title eD_batgTt .
(over)
DOH-1555 (02/2004)