Stark, Paul Forst VII IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr This Permit eau 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-2 .......... ....
Vittzge
Dist. No.E2.1:0..County....0 .-.AL-414-17. ri,--pNe oreity -9-,-- A.#*--4•4•"--...
(If city, give street address)
Name of deceased A-f-e -- a,- .9 -ar---r---/A-- Veteran .....----
Single, married, widowed, . (If veteran, give name of War)
SeX...?21rjo.)...0010f IA) or divorced (write the word).mtc Date of Dh4444—n../..i 19.6.71
Age ik- Cie Years Months Ar.Day ,,, _Birthplace ....gH,..ppp-i ...e.....
Cause of Death
Certificate was signed by "t jfrr_rlfrr-"l'?'s•;-je_/_yA,.-,„,..e.-- M.D.
Address )1 q
Place of Burial (or Removal) ../...4.4.--4.-,...---
(If body is to be temararily ld,fill In space later)
Cemetery Date of Burial. .414.•*-41.— 2' 4-- 195.9
(If body is to be temporarily bel ,All in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful encami-
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
Numbe45.and oltz..1.,3asis thzzfaXREBY GRANT A PERMIT
to gre'tot, -. , Ae,x.s.4 jt5t40. .7—*Zegi
N )
02,....84.44.1±ddress)
the 14. to hold temporarily d the body.
(Und ker or person baring charge corpse) (Inter,remcge,cipberal moose of[state how])
Dated if 19.5-f. (Signed) ie-4ree0--"' ne-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the State (eubject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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