Dougherty, Allen NEW YORK STATE DEPARTMENT .)F _ALTH'0
N.
Vital Records Section Burial -Transit Permit
Name Fr t Middle Last Sex
Date o Dea Age L' If Veteran of S. Armed F rces,
O-- 0a 1 pp/( 0.3 War or Dates lie s /9/ '-/9'/7
.- Place of De th Hospital, Institutio or
City,`ow or Village 4-kitty Street Address
141
Manner of Death Natural Cause 0 Accident 0 Homicide El Suicide riUndetermined ri Pending
Ili Circumstances Investigation
tu V Medical Certifier 3. Name n Title
AddreL_tzta
Death Certificate Filed District Number Register Number
City,Town Village -f �
Date meteryV
Crem ry
:::::❑Burial "�❑Entombment lIt ci) P i�'Yl..th-2,,�/
Addresstrm /
igiiiElCremation b (,f_-Q�Qiyt,
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
~ Hold
1/
0 Date Point of
v0 Transportation Shipment
L3 by Common Destination
Carrier
E Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iP Name of Funeral Home Ats,t., k--)--1,LitzArj
,, 0 1a-OS
Address (PCT CPLUAZin LAt G dA 46C ()-C V l�/ A21 ) 0 U`i 6
Name of Funeral Firm Making Disposition or to Whom /
14 Remains are Shipped, If Other than Above
2 Address
t
` Permission is h reby granted to dispose of the human rerrlai£as described above a ndicat .
Date Issued ,,:2 ( ii
2 Ja Registrar of Vital Statistics .�f-Z�,.c . 6 ---1c.�-rr
1
(signature)
>' District Number. 9r; s Place )icy /td_h
I certify that the remains of the decedent identified above we disposed of in accordance with this permit on:
Z
ILI Date of Disposition .-a,ci_ It Place of Disposition t n c J t e L..) CI^-e yr-1440 — it)V' 1
2 (address)
La
Cl)
C (section) (lot number) (grave number)
Name of Sexton or Person in C rge of Premises 1 pr-� 'i't ele0e
z � 1 (please print)
Signature 1A4v-4 Title Cr-e•P-mi-or7 1455 -
(over)
DOH-1555 (02/2004)