Allen, Billie-Jo NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiiiiiIi Name First Middle Last Sex
D ; 11 - .)o M , Arne,,.. F.
gii Date of Death A Age If Veteran of U.S. Armed Forces,
" g ) )ii c a I War or Dates ---
' Place • Death (j Hospital, Institution or
City Tow. • dlage . Qf. </,`' Street Address
Manner : Dec .Q Natural Cause �(]Acc4dent Homicide Suicide Undetermined Pending
Circumstances Investigation
&cc- /K Pct--&-Lo -.._ i it
Medical Certifier Name_- Title
Address
a iI 61,�. roi, s( . 1.-I� 5 , ti' las6�
«`- Death C rt' • ate Filed Distrjt Number r. _ Register Number
'; Ci own Village G�. c±' __ .5` '
Date A/ q r Cemetery or Cremator
VI Burial /A v. . I ( 11' (J�� - 6/e�, -�q LDS 6.y-�fc Jo-
Address
O 7
iii E Cremation `',
t�i.-c.e . 1�... t /t.-c._ / o, r-
gDate 7 Place Removed
O❑Removal and/or Held
9
and/or Address
Hold
O Date Point of
N['Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
in Permit Issued to Registration Number
im
'` Name of Funeral Home ,, ,c �I ,.k...e/<L . cJ -l. , . O�' ��
'<= Address 7
7,(lti_ /w, A�. 41,e. Kf ,--Z 4 ,� r J� e.)2_
,;,iiiii: Name of Funeral Firm Making Disposition or to Whom / / /
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human rifnains described ab p as indica pd.
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nii Date Issued g7 ei/14 Registrar of Vital Statistts4. :,�G ll) — . -
` _- (signature)
I District Number ,,5 Place / ®i--:A- ______yl /o``^ 1 0
7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1R
IDate of Disposition 8/9/96 Place of Disposition WGF Cemetery . Queensbury . NY
.+, (address)
i11
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Rodney G. Mosher
g (please print)
W Signature Title Superintendent
DOH-1555 (10/89) p. 1 of 2 VS-61