Rhodes Sr., Allen NEW YORK STATE DEPARTMENT OF HEALTH 4. I 14 32
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Allen C. Rhodes Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/19/2018 79 years War or Dates 1961-68
I- Place of Death Hospital, Institution or
Z City, To Street Address
iLLf Yl'��CRX City of Cortland 12 William Street
a Manner of Death latural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
t Circumstances Investigation
• Medical Certifier Name Title
.44 Matthew J. Karpenko- MD
Address
134 Homer Avenue, Cortland,NY 13045
gi Death.Certificate Filed District Number Register Number
City, To 1/14(Vifi09QX City of Cortland 1101 917
❑Burial Date Cemetery or Crematory
Entombment 10/15/701 R Pinpvipw Crematory
Address
remation Queensbury, NY
Date Place Removed
2 Removal and/or Held
0,❑and/or Address
F Hold
0_
Date Point of
CL
Q Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
: Address
7 Sherman Ave..Corinth, Ny 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
tJ
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2018 Registrar of Vital Statistics
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District Number 1101 Place City of Gartland
.•:-' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:
Z
tij Date of Disposition (0(is leg Place of Disposition R,l1... :wtt.--
(address)
Ili
CC (section) (lot num er) C (grave number)
dName of Sexton or Person in Charge of Premises P 34,- 1
Z / ! (please print
. Signature �.l Title 1171- I -
(over)
DOH-1555 (02/2004)