Allen, Sherwood Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. Town R ' tared No.t..1.6a..... .....__
Village
Dist. No. ..kvl.Coun or City — ,
/ G��a (If efts. [rr street address)
Name of deceased..,... ` Veteran
� (iE teleran. ire name of Was)_
Ingle, married, widowed, !'� � �`
Sex dolor/� r divorced (wnte the word) {. Date of nth ,/ .2 9
Age.... Y "rs Months Days Birthplace. . .. . ...... O•T'�r* //�•••
Cause of Death.._<., . ...... ........ .. .. . .
Certificate was signed ... .. .. . .... . M.D.
Address
Place of Burial (or Removal) I' 44(-4444-4-14- .
(If body le to be orari]y hel¢,fill in pace later) --"
Cemetery /�. i;rt...! +*r4eklei�Sr..� Date of Burial s .• /. 2 19
(If body is to b 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 ' • or. with,the .ve stated Registered
Number the b sis f HEREB GRANT A PERMIT so i .
to %.X °" h:.01 ' ..le 07 .ilei
the .... .../..::.. ............ . to hold temporari: .nd / the body.
(tradesr,7nvt charge of corpse) ,f/.'Int- / .•• r dispose •f[state bow])
Dated 7fJ
+� .�...19 (Signed) ! . c .. "
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (wrjeet to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 12) is required.
ENDORSEMENT OF SEXTON 'OR PERSON IN CHARGE OF
PHEMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date c�Y�/G ���,. er-1.9 CJ
(Interment or
(llama of Cemetery, Crematorium,
Section . .2 Lot No. ( f f Grave No.��
(Signed) 1E'��+, �
(person in c Ergo)
7J address (, �'�2�,�1,�,2
✓ l
Person in charge Host return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
RENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.