Allen, Ernest Ferns VIL Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or subregistrez) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTMCATF, OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No....../O_
or.GiVillagety0.7 _e____r_4_,L___, -
Dist Noj4/.... County..(-4Z:/c-4-1-"L.T..-eee--{ 4
(11 city,give stree d as)
Name of deceased .,. g-17' .4 , -4,.1'-..i. '
--/-' . j 6i._,ex2 Veteran
,s() i---Single, married, widowed, ) (If veteran. Give name of War)
Sex22,2aLC..Color.ek.laeft...or divorced (write the word).222.64-.'z.-:-/..e. Date of k_cec.A..ai/ -- ? _ 19. 6/
Age 6:$4 Yes 4 Afpnths. .. -.. .Days 7p
.2. /7 • place 3.7 .,!:.T.6...le.-e, 71.,..q....
Cause of Death t --f-A-19 fi...e.d. L-a'z-c-c-i --ig-.-.7:1--.-go...-
..,-,
Certificate was signed by "2:6 PiL":24:,-,-gq .46 - Q-:‘.i.i.-.3.,
M.D.
Address. (J) (/*--(41-.1..5.2 ---ift,": 77 . ,„,,
Place of Burial (or Removal) - 1.
(If body la to be jespporarily held,F (.,,
.!?ewe later) /,
Cemetery —,/ t/./.4,2-7 - # - --1,1e.ree...44-4:-.Z.-44-44. Date of Burial 4/7/../..":3,- 19,..T
(It body is to be temporarily held,Ali in sp a later)
Thei Certificate of Death containing the above stated pa "iculars, 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
Nult4and pn the basisf2„...th,to,.41l,tIER3;LGRANT A 1,1,ERNIIT
to. 1 PA4441-1 `7-1 i . !Ita-ye.2ke, .,---z.ek ..-Za.Zio., 91...
1.4444~-14,frame) ". (Address)
the •114 to hold temporaril and4,---Urzeg.... ;,.....1. the b dy.
(Rafeker or verso having chartalcorpel0 (Inter,remove,or, nose of[state bo
Dated V011 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pest of the State (subject to local
cemetery or other regulations),unless remora/is by common carrier,in which case a Transit Permit (VS No. 82) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
/� _
Date of" . was /l-G--c/ / - 194
(Interment or Crenation)
(Isere of tery, Crematorium, etc.)
Secti0446,2-c 13iot No. 3 Grave No., .r
(Signed) he)/ PCOCCA-9
(Person in charge)
Address 6—
>I
; .
Person in charge mist return this 194rmit 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 lords
"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.