Allen, Martha Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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—_:, ..,/
/ Village '//
Dist. No..,,,4.r : 'l.County... xr.:en- or City C -sr..-7 .-e- 4.,
,
/.. (If city, give street address)
Name of deceased....... ./.�C:.� t.....�. '`-- Veteran
Single, married, widowed, /�,'/i� ��j (►t "".a�aive name of wa<)
Sex it Color. or divorced (write the word).,-./Z:�tY.,.l2:....Date of Death ''",y .. .• .......191- Z-
Age 4-3 Years ) Months.''..hl .�........._...Day Birthplace -e . .e I)
Cause of Death (,..Z. �i. yam— ...
Certificate was signed bye..,,,. /. .. S���- M.D.
Address .��/', G. - C-�....)2 w....,;}
Place of Burial (or Removal) .o.?� 1.,` p�2--k �- y'
(If body Is to be terntempiirrily,keTd,01 wspace later)
Cemetery L..e4 47-e Gt- ,.l 1-.9 Date of Burial -J/ 19
(If body is to be temporarily he ,fill in space later)
Th4 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 on a basis thereof I HEREBY GRANT A PERMIT 7
// l�� ,-7,-, 7,.. )2)/
1g�s) , / (Address)
the G� er� to hold temporarily and....? the body.
(Undertaker or�f''' having charge of corpse) Inter,Kralove,or otherwise dispose of[state how])
Dated -4 ....? 19.L. (Signed).. . ' ... ... LUro Registrar
This Permit s sufficient for the Removal (and Interment or Cremation) of a body to any part of the 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
n
Date of .>�'�(4� -1, ,_._. .,,,f- was 7,_.2, -- 7 19 G Z
(Interment or Cremation)
/�/ �� „�Naae of Cem ery, Crematorium, etc.)
0 ?K r(5:-*s-,;. at'
3 ?1 C),IL a „
Section ,? Lot No. 3 Grave No. `)
SolJ/7-P Poll it— (,� Y..�'E'°L,-iJsCJ
(Signed) l l��V,1 1.4. V
(Peron In charge)
Address O ,( r, C O
Person in charge must return th 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.