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Allen, Helen • NEW YORK STATE DE 'ARENT'OF HEALTH 1 l I S Vital Records Section Burial - Transit Permit Name First Middle Last Sex Re Levi) - E �AV 5 ALL-EP -- m•ALE Date of Death Age If Veteran of U.S. Armed Forces, " `ThiW--'-kk 1 g ) t�a©1 ( War or Dates ckA 1 Place of Death Hospital, Institution City, n-.eV e 6.Leif,SVALLS Street Address 6 s 4 L,L, RoSP l mL Manner of Death'Natural Cause DI Accident 1=1 Homicide ❑Suicide ❑Undetermined ❑Pending iti Circumstances Investigation tu Medical Certifier Name Title 1 Vii billoh, Age.e.t r Addre U Death Certificate Filed District Number Register Number <> City,+own-er VillageG-t �,IDS �L L-S .c6 o/ 3 Nipli['Burial Date /Cremator ['Entombment CM caaj g...01 1 IreNnif IE op fc rr l Lk Y A Address 12°Cremation o1 k q U Pi-k6i R.c) 1t E E1y.S(SU RA-tA 0,?a4 Date Piece R moved Z F Removal and/or Held ❑ Address and/orHold 0 Date Point of an Transportation Shipment . by Common Destination iin Carrier Disinterment Date Cemetery Address • Reinterment Date Cemetery Address iiiiiiiii IDIli Permit Issued to Registration Number Name of Funeral Home ,. -( a57 TA ly E t : �3 (N c i 016741 Miii Address clD ✓molSiMU \ SrLAKF, G 2C )-n 1a , 4 _ '` Name of Funeral Firm Making Disposition orto Whom �( Remains are Shipped, If Other than Above Address cc ll ?37 Permission is hereby granted to dispose of the human Strains described bove as ndica =d. Date Issued / Registrar of Vital Statistics /TC__P_P ��(signatur ) igi District Number ( Place t /-0--�= 4 7: C I certify that the remains of the decedent identified above were disposed of in accordance with t s permit on: Z tail Date of Disposition 3-0-113 Place of Disposition s;�, ,zaJ oriv �, (address) LU CC (section) (l�o `'mber) (grave number) ci Name of Sexton or Person in Char of Premises I 't s SPAatF iZ (please print) lit Si nature (� it Title �01110fl miig (over) DOH-1555 (02/2004)