Allison, Sandra t it
NEW YORK STATE DEPARTMENT OF HEALTH A ` 1 w)c
Vital Records Section Burial - Transit Permit
Name First ` "Idle Last Sex
azAcAc� L. A 1 I ;So,
Date of Death Age If Veteran of U.S. Armed Forces,
I i g o t s 74 War or Dates _
F-- e of DeatJ Hospital, Institution or
WCit Town or Village C,�lc"s " Ur— Street Address (02^ - i)r H ,
❑ -Manner of Death 5 Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
la Circumstances VVV Investigation
at Medical Certifier Name ;� Title
CISu Lek A, uL.00* M t) .
Address tr.
Death Certificate Filed // . - ' District Number / Register Number
y, wn or Village t9 G.eA s Ta 1`S---- a24 7
Burial Date Cemete r Crematory
C/ D/ 01S— ir) HV.Cw Crematory„,_
❑Entombment Address
"r'1
(Cremation Lxik.,,e,--eA.s. Pe /ar�
• Date ) Place Removed
❑Removal and/or Held
and/or Address
1= Hold
i)
O Date Point of
O`0 Transportation Shipment
d by Common Destination
iiii Carrier
❑Disinterment Date - Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration umber
Name of Funeral Home •ft are u^cr.L. i44-4-,, J- 60
Address
, tr,4....- A-ve, t�r; IVY I a g aZ
Name of Funeral Firm Making isposition or to Whom
Remains are Shipped, If Other than Above
• Address
L
` Permission is hereby granted to dispose of the human remains described above as indicated.
�/�`j/ '
"Date Issued S J C.Registrar of Vital Statistics ( -AJrv-*
(signature)
District Number 5/d 1 Place S `\.s 1 N y
;_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition L jt I 15 Place of Disposition IN C-4,712",--
(address)
LU
tO
CC (section) �, (lot number (grave number)
pName of Sexton or Person in Charge of remises ""'' ut
(please print)
):„,„„„, Signature Title 42 V'iaL
(over)
DOH-1555 (02/2004) •