Allen, Willard rorm v01`I0.01. o-o-o.rau,uuu \1/-Ju/6,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ilir This Permit can be signed only by the Local Registrar(Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING ani acceptance of a CORRECT AND COMPLETE CERTIFICATE
OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. Noj.7-..3 Registered No. ' f
,J/ Town, '70 -
County.. U. Village .. (If city,give street address)
Name of deceased 1/Pd".,~1/
Z�1/ ��ingle, married, widowed,
Se Colorl/ll��iW or divorced (write the word) �%z�l Date of D th .. .,jor� 19.g`
Age 'if Years.... . 7 ,Months........o�... ... Da Birthplace.... �.rf.: ; ..r..97,
Cause of Death / .. ..
Certificate was signed by . ..k..... J.. . ... M. D.
Address T. �....�...
Place of Burial (or Removal) 40 i 4, , /I •
(If body is to 'tem ora 'y h in spa er
Cemetery. !!l„�il.. . ...p. .� Da e of Burial / 1 _
(If body is to be temporarily d, fill in space later)
_ The Certificate of De h containing the above stated particulars, having been presented t me, er careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num. and . , the ba thereof I HER Y ANT A PERMIT
i/ di/ aa 2/ #
ress)
the - i to hold temporaril an the body.
.. �r or n having charge of corpse) (Ixt r o , or othe ise dispose of [state how]).
A. r
Dated... !�� ....! 19 (Signed).... .. .. .s .
/ Ai Local R istrar
T •s Pe at is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local ceme-
tery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No.62) is required.
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