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Werden, Allen Form VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tar 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 and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.. 4 =WS Dist. No...5.62Q..t County Warren Village Lake. Georg.e sioxisr (If city,give street address) _ Name of deceased Allan Hs FiltratZt __ _ _ Single, married, widowed, Sex..1Lia*....Color.White...or divorced (write the word)...Ylidowek Date of Death J1112.0. 13. 1943 Age g 0 Years.. 2 Months.. 10 Days Birthplace fort...rtaward... .XR. Cause of Death Gar.onery.. .Thremb.aeim. Certificate was signed by Plaarles X. Bur.t M.D. Address Wu Govrge., N. Y. .. Place of Burial (or Removal) QUiten.ebUri,.. N• X• (If body is to be temporarily held,fill in space later) Cemetery JoAlclan uometerY Date of Burial. stiln... 16.. 1943 (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 statad...Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT ,.... ..... to Neil DA. Tripp 1,0%, Georgo„. N. Y. game) • (Address) the Vatar.tater to hold temporarily and into)? .,'-::- -the-504. (Undertaker or person having charge of corpse) (In ,remove,or otherwileAlsoo f[state ) Dated JAM. 15. 19..43 (Signed) .64 Deputy Local Registrar 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. 2 + 9, I! " o•w vO.w a'.7•.tiw.z..n. 0 ro o w .aw• o© Fr'- r.92 p.,. 0i y•, w w ti <'8 o .da r »', . • w •i 1Ul `d• aex., g •, o.g * 0 aq� roro »K a a'w �a•-E -ogel 0 Uq ad rowcoroC 0- '< O0i- o�)gro proa" w na _EC wM O�Grp-�naro'�0n� .N,Oro 50 y `',o, *w.aON S rO a 0 Ntwro� tl0 0 . trn 9. :. fir 0. C. • 2x e+ C."'5‘C o aa' a.a Vv' W2 °- rro Ca O wrwi" tar,*FO ,3Z Oda . . ,„ .• ro .+•5 OO N•5.p51.0 S5'µR,. Nrm a .. p.., tr-. - 0- 4 „2 2 ., 00 .i ^pMV l ' 15 d rop`C,ro w y rorotJ '� brysroV ON.►i TO tT 0fu w wO .typ, rn. r". p OO 0 .1 a0aa, r.n rte 0ay . ro .a.,< o a O o w y ,•*ro lTi0. 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