Allen Jr, Percy NEW YORK STATE DEPARTMENT OF HEALTH r Vital Records Section Burial - Transit Permit
Name First�Q�C,` Middle `L s�t Setc��o
Date of Death (� Age If Veteran of U.S. Armed Forces
015 -�. -k 1 5) �5C1 War or Dates
Place of Death Hospital, Institution or
-City Town or Village /0„..,:. .)
Street Address
la
p Manner of Death Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
tI Circumstances Investigation
iii Medical Certifier Name, 1, Title
II
�Address ' � (
�� 4i - v Cam ,! lCr�
Death Certificate Filed District Number Register Number
City, Town or Village
l Date ' Crematory
❑Entombment d " c
1 )"\ � 716)...9-i, CAaj ACA—t-s(�
Address Cremation \ f
�-W
Date - lace Removed
Removal
and/or Held
®, ❑and/or Address
0) Hold
O Date Point of
gi❑Transportation Shipment
3 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment
it
Date Cemetery Address
ill Permit Issued to 1- Registration Number
Name of Funeral Home Ui 51, rim k 00 ki
Address �ffi �\y\�c3/�( > M'i td 1�
Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
• Address
C
ILI
L Permission is hereby granted to dispose of the human ains describ above as indicated.
rw Date Issued -aji Registrar of Vital Statistics �3P\k V. (( k
F ,
(signature)
District Number s A Place \ CIN.VNC\ -':. --SCi:.)-(‘..A_,—,1
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.al Date of Disposition It Zed ea Place of Disposition 'Fr c A�,.✓ CrO r..
(address)
til
CI (section) A(lot number) (grave number)
pName of Sexton or Person in Charge of Premises tr4 5i
/j (p/ se print)
Signature !//(,�° 6 Title CIirj..bV(.
(over)
DOH-1555(02/2004)