Hause, Alfred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
"6; Registe d No. I f a
C �' t�ei Town, Village � ,
Dist. NO County or City '� e`�4"'
(If city, give street address)
Name of deceased � i Zei' Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex .---14. or divorced (write the word) /.. L Date of Death . ....3 19 ..2
Age Co "7 Years onths D ' Birthplace / '
Cause of Deathti..c1 � . ..se
Certificate was signed by .,d.... .. „t.0 .. M.D.
Address ...2..-....24a:4. eZ . ?...
Place of Burial (or R oval ri _
(If body is to be tern ra ily h'e d, 1 in space 1 5 /�
Cemetery �.,•,L- t-4 A-teci-- ...(Z i,4..4- Date of Burial �( 1973
(If body is to he to orarily held, fill in spac later)
The CERTIFICATE OF DEATH containing the above stated par iculars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have ecorded it in my , ocal Record with the above stated gistered Number, and on the b sis thereof I HEREBY GRANT A
PERMIT c� �.
to .. .. f L.�4 .............. A. '�0�'� `
Name} dare s) /
the ( _.,L.-,. to hold temporarily and C , V the body
rt erk' o� per n having charge of cps�s79 (Inte remov , or otherwise disp state how))
Dated
Y. l / J (Signed)
Il.Re711664a-'6
This Permit is ufficient for the Removal (and Interment or Cremation)of a body to any rt of e State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit( No. 62) is required.
FOOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
_ /
Date of- was 19 .9
(Interment or men}
' k 1- Y -1-:E2.A_ ,
(Name of Cemetery, —atc.)__
// -1 t 1(,la'I( C
Section Lot No. Grave No.
(Si( Li 2/----
d) ,
(Person in` Charge)
Address `�- l�`' t t':-r '• �_, . z..,%
Person in charge must 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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.