Allen, Virginia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First . Middle Last Sex
Virginia Allen F
[ Date of Death Age If Veteran of U.S. Armed Forces,
7-30-94 88 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address GFH
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Dr.Weinhold MD
Address
Glens Falls,NY
Death Certificate Filed District Number is r NurrJlaer
City, Town or Village Glens Falls 5601
Date Cemetery or Crematory
❑Burial 8-1-94 Pine View Crematory
®Cremation Address Queensbury,NY
Date Place Removed
Z❑Removal and/or Held
0 and/or Address
}= Hold
Date Point of
NTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home Alexander-Baker FH 0018
[ Address
Warrensburg,NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rern1lisSiO. 'y granted to dispose of the human renMns described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number 5601 Place City of Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Date of Disposition Place of Disposition
(address)
(address)
N
0 g ��� + �lotpu (grave number)
Ca
Name of Sexton r Pers in Char e of P mises /f�/�
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61