Allen, Edna Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sair 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 CERTIFICATEOF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
gistered No._...._��.._. .....�.-.--
Dist. Na -6 C'I Coun Le-) or City ��
J L/'/ (If city, give street address)
J/A
Name of deceased " t-r-�„ L-> `^'' Veteran
Single, married, widowed, (If veteran. give name of War)
Sex... .. . olor or divorced (wnte the word)' * Date of Death A 3 1941—
A Years. Months Days i place.
g Y 1
Cause of Death ���.
Certificate was signs y.... Q' M.D.
Address
Place of Burial or Removal) „.-- ..4.,..,,,„ ���..•.'•.• ��u �'�V
(If body is to be to orarilyheta �1�spac ater)
Cemetery.. -t 'L- ..... �...... Date of Burial Sr — ` " 19..4.2
(If body is to be temporarily held,fill 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
Num ►�'� on iri
s is thef I HEREBY GRANT A PERMIT ,r,a_16
the `•ll...n:. to hold temporarily and )
Address) ody
.
Y
(Undertaker or persgn having cbargyof corpse) er,r�move,orsotherwise diy�ose of[slat*bowl)
)
Dated T' 7 19.(o.:�— (Signed) -,�--C,t, ,�,)
Local
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the 'late (subject 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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
, Ih .
Date was - 2
(In terser :•myn)/
(Name of Cemetery, Crematorium, eto.)
Section Lot No. Grave No.
�'
(Signed) � k �47'
(Person in charge)
AddreSS�G G L �[.,i�'YJfGi���/
Person in charge must return this Permi
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.