Dunkin, Alan -4----) ---) LA i . _ -.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs# I R. Middle Last, �� k/ Sex
Date of Death Age JJ If Veteran of U.S. Armed Forces,
l '— (0 - II (..A-� War or Dates D 2//c •
Place of Death Hospital, Institution qr� g �ii 4 2„,/,2.6
w City, Town or Village L/k,QJJ0. . Street Address �� �� � re -�(
Manner of Death iii Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
iii Circumstances Investigation
tu Medical Certifier Namk c( e Title
ciaaacrifvt
Address
1OM . ( c 1� Aso /
Death Certificate Filed District Nu r Registeeer
City, Town or Village IN
[]Burial Daterietery o remator
❑Entombment Cremation Adddre s(s j-20a
G nU Pesb i AI / /c.,
( ,CJ4
Date Place Removed
Z❑Removal and/or Held
9. and/or
Address
Hold
0 Date Point of
VQ Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-4- 9L Ja,,,,,, ,4ce6/i/L/3
. • Address 9f,e°a-,e- _ Aiee/411__&v, /�
Name of Funeral Firm Making Disposition or to Whom /V
Remains are Shipped, If Other than Above
„ ► Address
OZ
ILI
IL
Permission is hereby ranted to dispose of the human remains descr'bed ov s in ' d.
Date Issued l // Registrar of Vital Statistics c -
signature)
District Number ,,Sr�/ Place 7 , /5 /(i>
r
i}- I certify that the remains of the decedent identified above were disposed of in accordancer with this permit on:
Date of Disposition I)II lit Place of Disposition 91,4,,(4.A...7 C t'�^-sf0
La (address)
U)
ir (section) (lot numbe. (grave number)
QName of Sexton or Peron in Char of Premises its 5ier" - 2il,st if
Z If j (please print)
IW Signature /ApL.. Title C Q C. mc.;o(L
(over)
DOH-1555 (02/2004)