LaPan, Gladys Form F&Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTIFICrATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Regis No.._......._.C:..
// Village `
Dist. No� 6 / Coup ....k�-)�x "`� or City
Al)at'LA'd 1. a-
(If e'ty, give streetya�ddLess)
Name of deceased - Te t FC)---1A Veteran .,[ /C)
v Single, rried, widowed, (If vet an. siv name of War)
Sex V Color... or divorced (wnte the word)... 14 Date of D / 0 19 -
.. ...
Age ��.(,�. Year M9,rlths aye ... ...
Birthplace �;• •
Cause of Death....... /d-�N--d- / -4-',�r .
Certificate was signed by C2.i?- , 1-0''� M.D.
Address -s, �. '
ll
Place of Burial (or Removal) e.k •lf d-4.--6i- ---, {••••,....'2 '
(If body is to porarny held,fill in space later �1 (�__-)
Cemetery......-'S-�,.1..,�-:,� :4g- V& Date of Burial j.. . 19 -)
(If body is to be temporarily held,fill in space later)
Thn 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 s d Registered
Num on the basis ereof I HE EBY GRANT A PERMIT y / /
(N
(Uncle ker pe n having charge (Address)
the ���h:\,... T�-.:4-:t...� �" to hold temporarily and �` the body.
corpse) (Inter,remov or otherwise svose of s to ow))
Dated `� / / 19.4. .=3 (Signed) � L.'
Registrar
This Permit Is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( Pict 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
Date o 1- / 1 was> ' Z3 19 LB
(Interment or Cremati
, ,-.41......- if/(01,-,,__,‘"--- 47'74-1:74:4-7"....-.1„.1; .
(Name of Cemetery, Crematorium, e )
Section ..::5- 7 Lot Nd.5-f Y Grave No. �'
F l
(Signed) �,,,.-, ,_ k,/�--�'a �
(Person in charge)
Address iiY�/'�%" !•" - i t��:-+-.•'''lr�.L'
- ' I,CP ,
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.