Allen, Martin d"
NEW YORK STATE DEPARTMENT OF HEALTH 111 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
al Pr'rZ T 1 N S. . A A.C. (J (v1
Date of Death1 Age If Veteran of U.S. Armed Forces,
D 1 1 c1 \ (9(9 610 War or Dates
t- Place of Death Hospital, Institution or
Z City TowJor Village G-RAN) \I 1 L-Le Street Address rt 4 OfZC /;( N unS)x...)t' CJTC
a Manner of Death Natural Cause El Accident Homicide 0 Suicide Undetermined Pending
W Circumstances Investigation
0
Medical Certifier Name Title
o bR . 1)g441eL GAR ►N1Gtir lr `Mb
Address
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Death CgItificate Filed District Number Register Number
CitkTovyyVor Village 6-RAO V ILL-6 517S4 4
❑Burial Date Cemetery or Crematory
0113010G, \�i N t✓ J l t✓u1 C:R e h i el i k,0 in
❑Entombment Address
RCremation Q V 0t;-r10(3U Ry , ('U ,\1
zDate Place Removed
Z ❑Removal and/or Held
and/or Address
I.: Hold
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
E
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M A-S0 iJ f)tJ i:TYZAL— \-kom 6. 0 I 1 g i _
Address
14s Cr C D 2Cr i; SZ 'P OB all 'co C A-1\)N,'(\{ y 1 , fs a
Name of Funeral Firm Making Disposition or to Whom
!_- Remains are Shipped, If Other than Above
2 Address
II
O. Permission is hereby ranted to dispose of the human remains described above as indicated.
Date Issued D I)30 TD C, Registrar of Vital Statistics 2 4 QJ Q1
(signatufe)
District Number 51 S(o Place ~fa V.'N 0 1= C-, 1\1 V t l_( - N\J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
gDate of Disposition 1L 3/-CC, Place of Disposition ih/). IItI C', ,1 ✓14 ig-te is 1 L) .(
W (address)
Cl)
cc (section) (lot number) (grave number)
d Name of Sexton or Person in Charge of Premises (�4'a i,' �¢ Q A) 'I
z , (please print)
W Signature C a, ,��,- L Title C a f!1/4 —1LU 7(
(over)
DOH-1555 (02/2004)