Allen, Jessie Form vs.SL, 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 CERTIFICAU Of
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. T , Registered No._,..:2.....e., -. —
___ ""- age
iret..-/-4-,
Dist Ne.. °/'County....... ---(- . ..:.•---..a....--2-7,—' or City ---
(If et toe street addrese)
Name oypceased }-42--'62--47---c---e-- C-) 66...'*('- ----1'17/ Veteran
•1 (If veteran, give name of War)
Single, married, widowed,(..e) • •
Sex ,.., Color or divorced (write the word) ate of De .ic. - -; / 19 4° -----
, eY A
se th Yeate_c.„...4.4.. ths . • % f ...' 4 - '
Cau of Dea Da-11,. -Ys
l'
Certificate was signed by /-7-9./? . M.D.
Address
Place of Burial • Removal)
(If body is to bez ri rily held, fill in_apnsce later)
Cemetery ..-4-- ---- .., --6.1
C11,....9---,,,,,‘—' Date of Buri ,/4. -.- '?7 19
(If body body is to be temporarily held,fill in apace 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 regi tion, have recorded it in my Local..Record with the above stated Registered
Nu and o the has' -there° I 'HEREBY GRANT A PERMIT " (Afir;tr,Z6
.4.1/
t ...... '`'pvir---iti
4'1 'L-e6-Z-v! (Na ddreas) /-
..the body.
(U de taker or person having charge 9:c r (Inter,remove,or otherwise disnose of[state bowl)
Dated .: .- -----, 19.,&2 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (esibject 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 SIX1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEBMEITS OR CREMATIONS
ARE MADE^ (fnter*ent or Cremation)
(Name of Cemetery, Crematorium, etc.) c 7
\
Section -� o Lot No.(/l Grave No.•
' r
(Signed) !c ,�_ �J yatE`r
(person in charge)
Address
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 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.