Saheim, Allen R # (6
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Allen R.Saheim Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/13/2022 60 Years War or Dates 1980-2003
Place of Death Hospital,Institution or
W City,Town or Village Hadley Town Street Address 59 Rollman Circle,Hadley Town,New York 12835
p Manner of Death EINatural CauseAccident Homicide Suicide Undetermined ❑Pending
1!J Circumstances Investigation
al Medical Certifier Name Title
David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed Town Of Hadley District Number Register Number
City,Town or Village 4558 2
Burial Date Cemetery,Crematory or Facility Name
05/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0ZElRemoval Date Place Removed
H and/or and/or Held
Hold Address
0
O. Date Point of
U) Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
i-. 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 05/16/2022 Registrar of Vital Statistics Colleen Demarsh(Electronically Signed)
(signature)
District Number 4558 Place Town Of Hadley
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition Si 1) I LZ Place of Disposition 11 Z :�
2 ' - (address)
W
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge fAremises
Z' / please print) /�UJ Signature Title L ifii( 41ki
DOH-1555(o7/18)p t of 2
r,,
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#