Mitchell, Allan W NEW YORK STATE DEPARTMENT OF HEALTH (1''''.7. '
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Allan W Mitchell Male
Date of Death Age If Veteran of U.S.Armed Fortes,
01/04/2024 82 Years War or Dates 1975-1976
1._ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death []Natural Cause Accident []Homicide El Suicide Undetermined El Pending
W Circumstances 1 lInvestigation
La Medical Certifier Name Title
p Marvin Davidowitz 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 6
ElBurial Date Cemetery,Crematory or Facility Name
01/08/2024 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
O[]Removal Date Place Removed
F- and/or and/or Held
N Hold Address
0
a Date Point of
U)DTransportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870 '
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
2 Address
C
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2024 Registrar of Vital Statistics legannroifagectronicaQySigned)
(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:
H
Z Date of Disposition III 9174 Place of Disposition '(S„4vc6,} AViT0A-X
ILI
2 (address)
W
CC (section) (tot number)Stiv‘ (grave number)
0 Name of Sexton or Person in Charge of Premi °"'' A.
Z lease print)
W Signature T Title (74
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#