Allen, Frederick Forza vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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— 12.-.
Village
Dist. No `i...- 0/C,ounty...-.Z., or City
(If city,give street address)
/.. ..
Name of deceased..........72-C4' ' --7..-.C.i.,. .. 1 Zr'.Z.:.....,(..e. Veteran 744
i "---.
gi i Single, married, widowed, //,,
' (II veteran. ve name of Wu)
Sex 2li Color..i'r or divorced (wnte the word)./it. . : Date of Death /./ 194-e
Age 7 7 Yeavx1 Months Days Birthplace
,-
Cause of Death )---).-e---r..-act--e.- .,.. -i .---t- -,---' '
Certificate was signed by f4. ---- . M.D.
Address. . ./r.C.a.--(7..,.. .
• . • )el' 2) Ci
3/4.....sy
Place of Burial (or Removal).
(If body is to be t77arily held,fl pace later),/ /t i
,- . 4`-r-v, d .1.11 Date of Burial 3/.1...5
(If body is to be temporarily held,dli 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 basis t ereof I HEREItyRANT A PERMIT
to (....rf./..-0-6 /it - -4.-c.-.--,-.4-:.-4..,.- i 7......1917r.i.-4. ...- .4...4.‘Z.,1; `IA-le•-g '&-
the Zi--e.,A hold ternpoy - d --- (Address)
(Undertaker or rson having charge of corpse) to (Inter,re e. r segetro tate howl)
Dated 3
Local Registrs.r
This Permit is sufficient for the Removal (and Interment or Crematio of a body to any part of the State ("abject 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 SEXTON OR PER )N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ojf/�� 2 ' 7ue? /r 19 t��
(Interment or (yure —)
•
(Name of Cemete y,: Crematorium, etc.) 1
Section Lot No. Grave No.
(Signed) (;/1G/'�� 3L ''`- `'J4 ')
.Z, (6
(Person in charge)
Address fYY ' Fz /4a4---- -1444,7-
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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.