Akins, Clara --..w vs.si- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 CERTIFI E OF
DEATH, LEGIBLY WRITTEN DURABLE BLACK INK. Town egistered No.__.._�.............
illag-e
fist. N .Coua ..�-�l�(:1+¢ :- �.
orreity ..`
J... (If city,give str t addrgs)
Name of deceased L&1 . :" •.• ....[<.i i$ Veteran .
as
[ ��--�� Single, married, widowed, (IE veteran. Give name of 79)4
S . .. .. 1o1r4o �..or divorced {wnte the word) Date o --th.,..., Q �'
A ars 0 A thg, ... .....Da irthplace riiA i R
Cause of Death ` .. , • M D
Certificate was signed by ..
1 p e
Address �^^^ M
Place of Burial (or a e oval). .1.•
If body is to re tempo i . d,fill ter •
/ 1
Cemetery... ..2., .r.. 0 . . . .. .. Date of Burial /.JO - �• .2,-
(If body is to be temporaril held,fill i 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 accept the same for registration, have recorded it in my Local . ec r with the above stated Registered
Nu and • b • t f I HEREBY GRANT A ERMIT - 2(i
I.D.
to r... .a..S V 0 7 •
e.ddress)
the to hold temporari nd t e body.
( dertaker or verso/having eh rgivof
corpse) (Inter,remove,or Ts ose of (state how
Dated (Q.....r l 19. 2 (Signed)
-al Registrar
This Permit is 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.
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ofG "�"--7 was( 14/. /J 19 `-z--
(Interment or Cremation)
1
‘,(----„ic,.-
: ._�,
e....; .....
!(m�'e o':' Cemetery, Crematorium, etc.)
L._
Section Lot No. Grave No.
..
(Signed) ,-6-4
1iiic--... ��-��-�+"'�
(Person in charge)
Address Jf\ C Z L ze. i
r
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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," acid 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.