Anderson, Allen Form VS.at NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
yr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow,,,
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.
LL` f Town
Dist. Ns>a. County.. j7.. .. .. . . . .... .. . . . .
1 may. (If city, ive -eet address)
Name of deceased ..... w.. . .. F... . • •
) s /
_ n �(; Single, married, widowed, ti
S GJ� ..Color . U.,�,Ror divorced (write the word .�' E1: e • Death.. ..t.. .2 19#
Age 13 Years ? Months ,jJ Da s •-rt t . • L. L..u.GJ.IRt41n..e0..iij
Cause of Death ' di �/I�r,�� ' I' • • 4 , , 1
•
Certificate was signed by. .'+ s/s ri a y M.D.
� ..
I
Address ...: .. a id, F '..�7
Place of Burial (or Removal) �` Y.?� _ • • i� ,� tlekt..A./La4^4h,
(If body
is to be t•4 porarily h`,, fill in space later)
Cemetery - .0 . .o l... Date of Burial... , 7 19* --
(If body is to be 24 orarily held,fill in space later)
The Certificat- of Death containing the above \ated particula s, having been presented to me, after careful exami-
nation, the same appearing to be COM ETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registratio , have recorded it in my Local Record with the above stated Registered
N er, and on th sis t f I Tr<4131', ANT A PERM T )iik.i...a...leal. crltiria. 14
[ ess V
the to hold temporarily and .. the body.
Undertaker or person having arge of orpse) ,.(Irate re e,or raise dispose of [state how])
rated „ . � i..� 19w`?`. (Signed) ,.... v`4
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crema ' n) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in livhich case a Transit Permit (VS No. 62) is required.
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