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Allen, Ronald NEW YORK STATE DEPARTMENT OF HEALTH if it 5,� Vital Records Section Burial - Transit Permit Name First Middle Last Sex K,A A.I_J� A-Il. M Date of Deat / Age If Veteran of U.S. Armed Forces, t I /?-`7` //r 7)-- War or Dates t- of Death / Hospital, Institution or t City own or Village C9� i � Street Address C9 ---«.-,i,--} '..,y' ErVranner of Death®Natural Cause Accident 0 Homicide �Suicide � Undetermined Pending 0 — . ` Circumstances Investigation Medical Certifier Name. Titlefitti,,A . S Address � J � ��(� /> ' -CI r D-- • Certificate Filed ,- District Number � ) l egister Number . �own or Village C9 4�--� �� :J © O ff Date Cemetery or Crematory [� Burial )l / 2 5— 7i ' „QEntombment l `� v' �-` � Address v [ XJ �Cremation C , -cA 5,6.,r I /U Lo r✓' • Date 3 Place Removed Z❑Removal and/or Held 2 and/or Address f= Hold N O Date Point of 05 0 Transportation Shipment • O by Common Destination Carrier Q Disinterment Date Cemetery Address . 3 Q Reinterment Date Cemetery Address 43 Permit Issued to _ Registration Number Name of Funeral Home GnS A-v 2 —7,�n«„� 1-4 .tr .4-t- • (j0 Li-71 3 Address 7 C G,- .7,' AN( /, 0 y /) �(V ?— Name of Funeral Firm Making Disposi osii ion or to Whom -' Remains are Shipped, If Other than Above ;2 Address • LEI Permission is hereby granted to dispose of the human remains described as indicated. Date Issued ))/2-c/I Registrar of Vital Statistics O,es_o _ _ Uk).iv (signature) District Number 5 bo I Place 6 S `\� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iti Date of Disposition 11/3011c Place of Disposition /et.0,.,4 eirrikrtara . 2 (address) LTik til C (section) (lot number) (grave number) gName of Sexton or Person in Charg of Premises (,rf pl,y-- &nu'I- Z 1 I,, (plleease print) i Signature Title (over) DOH-1555 (02/2004) •