Allen, Merl Rhodes �' t " sq. 5Pi
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Merl Rhodes Allen Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/09/2023 67 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 10 Kvale Lane, Hudson Falls Village, New York 12839
pManner of Death ❑X Natural Cause IllAccident El Homicide Suicide Undetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
0 Gerard Abess MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 2
Burial Date Cemetery,Crematory or Facility Name
01/17/2023 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
CO
0
a Date Point of
(/)❑Transportation Shipment
p by Common
Carrier Destination
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
t Remains are Shipped,If Other than Above
2 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/12/2023 Registrar of Vital Statistics Cynthia Bailin(ECectronica1Ty Signed)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition I (h lib_ Place of Disposition 'Pb(L (.vita
IJJ
(a dress
W
CCCC (section) (loth er) (grave number)
gName of Sexton or Person in Cl re of Premises 7 /1„.. 4- n7rt
Z ir(please print)
W Signature i7. Title ��'/b/�1�'v2
DOH-1555(07/18)p 1 of 2
0 1 b' C; .
', 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#