Allen, Brett 1
NEW YORK STATE DEPARTMENT OF HEALTH +, Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Brett Allen Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/31/2022 61 Years War or Dates
F., Place of Death Hospital,Institution or
W City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing
p Manner of Death 0 Natural Cause Accident Homicide 0Suicide nUndetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
O Joshua Starteri NP
Address
17 Madison St,Granville Village,New York 12832
Death Certificate Filed Village Of Granville District Number Register Number
City,Town or Village 5725 01
Burial Date Cemetery,Crematory or Facility Name
01/04/2023 Pine View Crematory
Entombment Address
(Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
- and/or and/or Held
H- Hold Address
0
Date Point of
N❑Transportation Shipment
a by Common
Carrier Destination
Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i... Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/04/2023 Registrar of Vital Statistics Diana ScarCotta(ECectronically Signed)
(signature)
District Number 5725 Place Village Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~
W Date of Disposition /G,-1oa3 Place of Disposition ; Aie LA � f (address)T0,..)
r
W
LC of number (grave number)
CO (section) J ;�
8 Name of Sexton or Person in Charg f Pre ' 7 no.J:J
(please print)
• /, Title O �r't-
i nature �i�Signature
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#