Allen, Donald NEW YORK STATE DEPARTMENT OF HEALTH ; _ a # &to 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald William Allen Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 15, 2013 66 War or Dates Yes 1966-69
Place of Death ty of Glens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Villacgt Street Address
Manner of Death El Natural Cause ❑ Accident ❑ Homicide El Suicide riUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Bergin MD
Address
3767 Main St. Warrensburg, NY 12885
Death Certificate Filed City of Glens FAll District Number .s — Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
July 17, 2013 Pine VIew Crematory
❑Entombment Address
®Cremation 21 Quaker Road Queensbury, New York
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home Registration Number
Name of Funeral Home01078
Address
136 Main St. SOuth Glens Falls, New York
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 remains describ d!abve a�,indi .
Date Issued 7-1 7-1 3 Registrar of Vital Statistics , `�'
(signature)
District Number 5601 Place City of Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1-t113 Place of Disposition Juw Cw.-c(Tr,---
(address)
(section) (lot .mbar) (grave number)
Name of Sexton or Person' Charge of mises r''�i ç
''
(please pnht)
Signature Title ($4/4TO
(over)
DOH-1555(02/2004)