Allen, William Form VS.IL 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 Registered No. 3.. -3...
Village
Dist. No -6C.4...County..: / or City ..... . ....:: -6 ;
� L (If city, give street address)
Name of deceased 1., 1- J ✓..: �Z?&- ri Veteran - -c--e
Single, married, widowed, (If veteran, give name of War)
jySex...,i.1 l Color.. or divorced (wnte the word)r a : r.......Date of Dept11 /l,l.• -- 19•4.4:—
Age jr...: ....Yeaj Months D y Birthplace -,Z—L..z. .. . ..4� e:g,...?l.&fr/..r.
Cause of Death c -C: 44� .2 ... .1---rs',4
Certificate was signed by .a�,..6 - .. M.D.�
1 G
Address G.l�z '2 �/ ti
vi
Place of Burial (or emoval) 7-6,� ram.. f v
(If body Is to be tempo ril held,fill in space later) C Date of uria] /� S 19...di
Cemetery ..mac.. .�• .iw:.�-x.=-.�.,•:•
(If body la to be temporarily held,1111 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 bad ;hereof I HEREBY GRANT A PERMIT/
to .s1
4----(Name)/ "� (Address)
the X.Z .4:: to hold temporarily and.�L the body.
(Undertaker or rson baying charge of corpse) .- i (Inter, ,move orr�.herwlse dlsnose of [state bow])
Dated /1 ,/....�C.- 19...,..} (Signed)�.�:r4-:-t � t;r-cl-A / ;..1
/ Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (eebject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SE ION OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CITATIONS
ARE MADE
�
Date o 7Z 2,j -5 19
..
_ (Interment or
.... .
---)/ ----7,2-
�...__ ,/77...„_ .e. , C._��-.. -cam--'
t
(Na of Cemetery, Crematorium, etc.)
Section Lot No. //1 9C—Grave No. Z
(Signed)7.7.'
.i',�� �£� _ . C. C
(Person in charge)
Address ��(/ .,AY .
-� Cv /
Person in charge must return this Permit tpr •
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"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.