Allah, Prince NEW YORK STATE DEPARTMENT OF HEALTH �, Burial - Transit Vital Records Section
Name First Middle Last Sex
Prince Shaleak Allah Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 17, 2013 46 ` War or Dates
F•• Place of Death Hospital, Institution or
W City, Town or Village Hudson Falls Street Address 285 Main Street
W Manner of Death Natural Cause Accident Homicide Suicide 0 Undetermined 11 Pending
Circumstances Investigation
WW Medical Certifier Name Title
CI Max Crossman, M.D. Dr.
Address
Whitehall Family Health Whitehall, NY 12887
Death Certificat d`' District Number Register Number
` City, Town o Village ttv.c,Sarn � et,1 ...C7 a( l la
❑Burial Date Cemetery or Crematory
October 22, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
p and/or Address
j, Hold
VI Date Point of
p„ ElTransportation Shipment
CO by Common Destination
CI Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
11I;
11. Permission is hereby granted to dispose of the human remains docorihed above indicated.
Date Issued 16`al',;6 13 Registrar of Vital Statisticsv t
Y (signature)
District Dumber,j 76 a. Place '11,. rCCA9-3�-�,. \A '(--1
F I certify that the remains of the decedent identified above were disposed of in a/c'cordance/with this permit on:
WDate of Disposition_ to1L3jI Place of Disposition .ZI / "fy*�IDr�
5 (address)
Ili
G/}
W✓ (section) lot number) r (grave number)
• Name of Sexton or Person ' Charge of remises rry 1h�+1 f
0
Z (ple se print)
W; Si nature Title C
arroAti
g
(over)
DOH-1555 (02/2004)