Wallace, Addie Form VS.M. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
vir This Permit can be signed only by the Local Registrar (Deputy or subresistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 309
Town Dist. No..5.5QJ.....County...:iar.r.en. 'Village... 3...P1.110. .;:t....,.0.1.en.s...Ea.11.s.,....Pd..:':.
or City (If city,give street address)
Name of deceased Ad ,3.Q... ', dlalla c e
F e 7,a 1 Single, married, widowed,
Sex ecolorWh5.to or divorced (write the word) W1 .Q:z .d. Date of Death.NQY.......2 .,. 19..39
Age 7,1 Years ---- Months 1.9 Days Birthplace...G i.e.t.S...F.a.i.1.S.,....L.....Y
Cause of Death.-jz:grt9n$ion Eyoca.rc1ial de P.;;1P,1^,a.:.?:P?f?i-.5...y..t'A.:.C.a.r..d .aQ...I)e.a rlpansa.tian-5
Certificate was signed by AI'..,...J.....:7.......1I?k�,.1.fi.t QXl M.D dY
Address al.B.I:1S...Fall.s.....:iN'......Y.,,
Place of Burial (or Removal) t, A1,phonsu s Ce m s d 7ep;tt Q.1 er1,,S,fta11, , ,1T.a y,
(If body is to be temporarily held,fill in space later)
Cemetery $t• Al,Pil o n AP,O...QA fi!4 t.O.I'y Date of Burial Ntt.V.,....2.5.,. 19..39.
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, 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
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to Loren 'y. 5in, ,leton . G1.oxla...k:a...s.,....NA...Y..
(Name) (Address)
the IVil:OCCIP...1.1ndartaker to hold temporal.' 13 the body.
(Undertaker or person having charge of corpse) ye,or pose of[state how])
Dated NOVA ?5.s. 19.39... (Signed). ......
Local Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No.,62) is required.
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