Allen, Elizabeth D €111
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elizabeth D Allen Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/30/2022 47 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address 22 Morgan Avenue,Glens Falls,New York 12801
CI Manner of Death 0 Natural Cause ❑Accident IIIIHomicide Suicide Undetermined nPending
W
U Circumstances I 'Investigation
W Medical Certifier Name Title
t7 Thomas Portuese MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 188
Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
O❑Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
O. Date Point of
N nTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
nDisinterment
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
.. Remains are Shipped,If Other than Above
.M Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/01/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionIy Place of Disposition 'line VI-. � r
W Date of y i ZZ P
2 (address)
W
Cl)CC (section) I (lot number/CC (grave number)
0 Name of Sexton or Person in Charge of Premises /1w t/p (--- s�Gh nl�
ase print) �y�
W Signature ��' _may Title ��1`lMl —
DOH-1555(07/18)p Lai 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#