Allen, Lois (, I
NEW YORK STATE DEPARTMENT OF I- ALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lois W. Allen Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 09, 2013 75 War or Dates
1= Place of Death Hospital, Institution or
WCit Town or Village ofGranvilleStreet Address Indian River Nursing Home
p Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
la Circumstances Investigation
Lij Medical Certifier Name Title
CI Susan Sperry Nurse Practitioner
Address
t 17 Madiosn Street,Granville NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village of Granville 5725 40
❑Burial Date Cemetery or Crematory
November 12, 2013 Pineview Crematory
QEntombment Address
. ®Cremation 40 West Mountain Road,Corinth, NY 12822
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
CO
0 Date Point of
u)Q Transportation Shipment
G by Common Destination
Carrier
$ Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
77- Address
7 Sherman Avenue,Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
II- Remains are Shipped, If Other than Above
Address
C
tit
a Permission is hereby granted to dispose of the human remains d-- ' ,y ' dim ted.
i.- Date Issued November 12,2013 Registrar of Vital Statistics : ► VA SW
(signature)
District Number 5725 Place Village of Granville
1~ I certify that the remains of the decedent identified above were disposed of in/accordance with this permit on:
W Date of Disposition /f'f g-'/3 Place of Disposition //V �iy.✓ 1 ir4=" r
2 (address)
LU
Ce (section) �e.0 ti Anb�er) cl (grave number)
0 Name of Sexton o ers i ,C of Premises
Z � / ce.70.0.1(please
print)LtSignature ^C Title '/7'C_
(over)
DOH-1555(02/2004)