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Allen, Stewart NEW YORK STATE DEPARTMENT OF HEALTH Burial ® T�'ans � �����t Vital Records Section Name First Middle Last ,rN I, \ Sex M -1-evJ ar-t- ri t 1 Age If Veteran of U.S.Armed Forces, Date of Death 03 I I(� I ZO 1 1 g 1 9 �`<=` War or Dates i 9 tvO-H 69 6, Place of Death f Hospital, stitution orn t- J..i� i' own or Village O I en c Eat t If Street Address lS)errs 1-a,t J s l xo s l �CJ-i -iiii_Manner of Death a Natural Cause 0 Accident ❑Homicide El Suicide 7Undetermined El Pending Circumstances Investigation la Medical Certifier Name -- (1 1 Title CI v en(1 l P Cc/ 4 rR,Tfo r- Address ILL 1 6 . Cc reLf iZel Qut-e-ens 6 vrc 1\J.q 1 z'd LI --. Certificate Filed rThDistrict Numb Register Ter own or Village �F3' S Fi S rs ,4.5 d/ ■Burial } Date ( Cemetery or Crematory., ❑Entombment Address //�} Y �/ remation Q c1ker Rd• W u.e�f b“,i-c, r lV./. /a 8'd q Date Place Removed I—Removal and/or Held and/or ; Address Hold 0o. Date I Point of Q Transportation Shipment cl by Common Destination Carrier El Disinterment Date Cemetery Address l'. Q Reinterment i Date I Cemetery Address Permit Issued to 1 Registration Number Name of Funeral Home t:.. �'\C=. '� t- s1�1 x\ op \t- c:::t‘ " 0 Address - f 1-2,c Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above Address I Ili nii Permission is hereby ranted to dispose of the huma remains described a•+ove as indior Date Issued ©- Registrar of Vital Static ics Al_ f_<i / ` L ,A..y (signature) ::i. District NumberQ Place /l I certify that the remains of the decedent identified above w'•re disposed of in accordance w this permit on: Z. Place of Disposition 2j�G�-t l' e fir) - x' 3f Date of Disposition7/7 P (address)(11 re Y ILI (section) tot number) (grave number) Name of Sexton or rson'n har e of Premises 3 a I(G✓! 4-/r2 4 (please print) Signature 4 Title L"-e mom/ (over) DOH-1555 (02/2004)