Allen, Dorothy L. r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Muddle ] ast Sex
o L. G irk
Date of Deat Age If Veteran of U.S. Armed Forces, _
War or Dates
i- Place of Death / Hospital, Institution or /^
Cit , own or Village L" Street Address YO
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑P riding
Circumstances Investigation
W Medical Certifier Name Title
6A�\'. L Garb e ;
Address
�� ter✓ ��„ l� 7 a ��
Ch Certificate Filed District Number S� 0 Register Nmb}e�r
own or Village 1-u-�'`� S
❑Burial Date Cemetery or Crematory
❑Entombment Address M
remation cX� �-� L
Date Place Removed
Z:❑Removal and/or Held
and/or Address
�= Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home - ,r„•Xf
Address
V
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
lit
Permission is hereby granted to dispose of the human remains described above as indi_catedd..--
Date Issued j'3 i Registrar of Vital Statistics
r (signature)
District Number Place s
;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition ra_1�t/q Place of Disposition P. 0,0 V,'o,,,,3 1 Lg*1+'►a-w r �
2 (address)
11
(section) (lot number) (grave number)
p Name of Sexton or Person in Charg of Premises 1�Af1iay.-'
AAf
(please print)
. Signature Title af-yx4cl""
(over)
DOH-1555 (02/2004)
t
Public Health Law Sec. 4145(2b) 01
i
1
Receipt f
Human remains of delivered on , 20 '
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#