Allen, Cynthia Marie . tf 3in
111)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cynthia Marie Allen Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2022 64 Years War or Dates
P Place of Death
Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death EI Natural Cause Accident Homicide Duicide FlUndetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 224
Burial Date Cemetery,Crematory or Facility Name
04/25/2022 Pine View Crematory
Entombment Address
fJCremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
N
0
O. Date Point of
t/) Transportation Shipment
Q by Common
Carrier Destination
o
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/25/2022 Registrar of Vital Statistics .£Megan Alban g(ectronicalTy 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:
I—
Date
W Date of Disposition y Its I it Place of Disposition ?nc1L.. 47)(14.„,:
(address)
W
NLE (section) (tot number) (grave number)
G Name of Sexton or Person in Charge. f remises A,Lt4 11 ti
(pi print)
W Title rPm474.
Signature
DOH-1555(o7/18)p t of 2
iu1
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#