Conklin, Robert Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistra.r) 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.__.._.4__O...Z....._
ban Village
Dist. No 198 County.........:'...l.?.....Y or City 113 Ho 11itic.4Y.allutti rU.bany.,...htew...Yark...
(If city,give street address)
Name of deceased Robert E. cp}} i.n Veteran
(If teleran, give nerve of w.:)
Single, married, widowed,
Sex .' Color....Whi.tte..or divorced (wnte the word) "fahrigd Date of Death 10/26 19 62
Age Years Months Days Birthplace x.Z. ..gdwal.Xsi.,...Xew...Xar .
Cause of Death i`iImaxSi?41...I};tfaretiior
Certificate was signed by WilLisaiii...at i,akq M.D.
Address V&.Ji.P.agi, a2 Albviy, New York
Place of Burial (or Removal) lAtdri...4).f..Quge1}sbcmry,, New York
(If body is to be temporarily held,Jill in space later)
Cemetery 1 i.ne lei Date of Burial 10/29 19 62
(If body is to be temporarily held,fill in apace 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, and on the basis thereof I HEREBY GRANT A PERMIT
to Charles K. _Le, a. ...a..........
the Undertaker (Name) to hold temporarily and Inter (Address) the body.
(rade er or person having charge of corpse) (I r,remove or otherwise disoose�of�sta howlll
Dated /ffr .`.�a 19 (Signed) ..., , r --04.- ,-- .}f-"
Local 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 currier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SENIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of -A-. _-. ( was L._/l" . -- 19 F=' -----'
Interment o
7 ' ( ---7- -- --- .------
, , . ,, , , _ ..,...____,_. ,---;;„., ,..„ ... 7 -
(Name of Cemetery, Crematorium, et )
Section -- l--- Lot No./ 7 I Grave No.
(Signed) %/1.�‘ J .`i -C-f7L L-
(Person in charge)
Address _6 ‘,1 —( (,��) t?>7._���`_"-.--"_. . 4,,, 4-.K ""
' /
.., , 7 L
Person in charge must return this Permit to 7
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.