Allen, Donald . 1 I /%�
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dona-'-d W. Allen M
Date of Death Age If Veteran of U.S. Armed Forces,
03/1 3/201 6 63 War or Dates 1974
M Place of Death Hospital, Institution or
City, Town or Village Greenfield Street Address 526 Locust Grove Road
Ilia Manner of Death I-4�I Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Ili Circumstances Investigation
la Medical Certifier Name Title
George Siniaphin Attendi n4 Physi r:i an
Address
600 Palmer Ave. , Corinth, NY
Death Certificate Filed District Number Register Number
City, Town or Village Greenfield 4557 5
❑Burial Date Cemetery or Crematory
03/15/2016 Pineview
ii' ['Entombment Address
>< glCremation Oaeensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
H Hold
Cl,
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
ffi
❑Disinterment Date Cemetery Address
❑Reinterment 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
i
P' Permission is hereby granted to dispose of the human remai descri d "bove as i icated.
iiiiil Date Issued 03/15/2016g Registrar of Vital Statistics - l
,,��11 (signature
District Number ' Place e/A---
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til▪ Date of Disposition 3 I1S*i j k, Place of Disposition Zit..
(. st--0
(address)
w
CA
CC (section) / , (lot numbed (grave number)
et• Name of Sexton or Person in Charge of Premises iir,it. ,... ..1
.z. please print)
Signature ZL .2,0t- Title f t Y1 _
(over)
DOH-1555 (02/2004)