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Allen, Jeanne C
4 \Ijl/I NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeanne C.Allen Female Date of Death Age If Veteran of U.S.Armed Forces, 07/16/2021 93 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Fort Ann Town Street Address 238 Hadlock Pond Road,Fort Ann Town,New York 12827 G Manner of Death © Natural Cause D Accident 1=1 Homicide ❑Suicide Undetermined E Pending UCircumstances Investigation Ili Medical Certifier Name Title a Courtney Bowers NP Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 4 ❑Burial Date Cemetery,Crematory or Facility Name 07/17/2021 Pineview Crematorium EIEntombment Address Cremation Queensbury Town,New York ❑Donation ciRemoval Date Place Removed Eland/or and/or Held Hold Address to Transportation Date Point of by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom } i Remains are Shipped,If Other than Above 'S Address a ILI a' Permission is hereby granted to dispose of the human remains described above as indicated, Date Issued 07/16/2021 Registrar of Vital Statistics Barbara J Winchell (Electronically Signed) (signature) District Number 5754 Place Fort Ann, New York 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition -7-/-7.4 L) Place of Disposition jr` de IA'e,,.J ere-pm-4 r^--( (address) ill In §. (section/ / (lot numbe/ (grave number) Name of Sexton or Person in Charge f Premises �g�/�/o."rA El. /O Z (please print) e. tad Signature V- Title r r-PS r! — DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) " 1 1a 4 9 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# • = <