Allen, Randy James NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Randy James Allen Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2022 50 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Wilton Town Street Address 24 Northern Pines Drive Apt 1,Wilton Town,New York 12831
p Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
uU Circumstances Investigation
U
LLt Medical Certifier Name Title
David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Gansevoort 4569 1
Burial Date Cemetery,Crematory or Facility Name
01/11/2022 Pine View Crematorium
Entombment Address
x❑Cremation Queensbury Town,New York
▪Donation
ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
O. 1-1 Date Point of
tl) ❑Transportation
p by Common Shipment
Carrier Destination
•
0 Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
LLF
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/06/2022 Registrar of Vital Statistics Susan(Ballwin(Electronically Signed)
(signature)
District Number 4569 Place Gansevoort, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Date of Disposition (/)y I ZZ Place of Disposition
c (address
W
CC (section) dot number) (grave number)
C
Name of Sexton or Person in Charge of Pr ices 6 n►i1p�T Je*l& 1t
(pleas print)
W Signature Title iFM4.1;tl
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#