Taft, Allen NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rie This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilhage, 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. Q
r Town, Village Registered No. ... J
Dist. No. ���' ! County UDaiy or City (3) 15 Fd.1 L
(If city, give street address)
1
Name of deceased �1 1\6 V ) U'U Ta-F+ Veteran .. e " 1,4 L() IL
(If veteran, give name of War)
Single, married, widowed, --
Sex Ma je- or divorced (write the word) .(Y) l C-CI Date of Death ..0 nf-- 0-1 19 —15
Age 6.. Years , .Months Days Birthplace
Cause of Death CDr�.1.E.C~ c j..l.are g .C. c: ,
Certificate was signed by NI.Lunc. ., S-+ . M.D.
AddressC.1C. r °1 -0 5 'a t 1S
Place of Burial (or Removal)) ... O.ei n-- [?.l lr
(If body is to be tem arily id fill in �ater3 1
Cemetery ..:.....I .. hon,space 4 ...e. � 1- .�.1.� Date of Burial `�.. r-)e_ 1/ 19..�5
(If body is to he temporarily hel , fill in space later) J
The CERTIFICATE OF DEATH containing the above stated particulars, 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 recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT T
to r\ ll l�t aE,1'1Aq l r1C. . `( ,
.t I,t _-t.c- Ed eY.1 f-b
ff''(Name) 1 Ad ress
u.(n :y�the . :.C.:er to hold temporarily and ( n it i- the body
(Undertak or person aving charge of pse) (Inter, re , or ot_ se se (state how))
Dated :Kt. Ilo 19.APO (Signed)
a!f��s�fst�
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any par file State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM 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 v c7 "'1' was L'yi.Q. /7) 197-5—
(Interment or Cr ation)
Iderriaio Ce4
(Name of Cemetery, Crematorium, etc.)
Section L /(Otrl l Lot No. I Grave No.
4
(Signed)
(Per on in Charge)
Address �� 71.-�A `j ) II/ V
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, d
FILE PERMIT WITHIN THREE (3) DAYS with the Regi r
of District in which cemetery is located.
1114
SEXTONS, FUNERAL DIRECTORS and UNDERT S
violating the law relative to the return of permits are lia o
a penalty of NOT LESS THAN FIVE DOLLARS NOR E
THAN FIFTY DOLLARS FOR THE FIRST OFFENS e
law will be enforced. Local Registrars are required, r
penalty, to report violations thereof.