Allen, Carol NEW YOKK J I A-1 E LEPAKI MEN-1 ur 1-1r L 1 ri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ,,
Town, Village c
Registered No.
Dist. No. l... /- County or City
y (If city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
p� Single, married, widowed,
Sex �`a .. .... or divorced (write the word) Date of D th..��L.c.e rt�t.Qi+ 1 /7.
__
Age ' 'L3--- Yea,JJ�- 4� ]Months Days Birthplace..�� ......... 4:�0... .:. .
Cause of-Death (..'t. mac. c3J!t�3.�saCs.�
Certificate was signed by..... .. a . - ..1..' M.D.
Address0 7,.,._..,,�� .�.cJ :.. _. °� .�r.,-- =-
Place of Burial (or Removal) _ J
�.� ea
(If body is to be to arily Idy�ffll in,space later)
Cemetery .a aRrep.) -z ,.e0l Date of Burial.. ,!��C 19.��/
(If body is to I$e temporarily held' II In space later)
The Certificate of Deat containing the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to he 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
Num and on the Wis tirreof I HplEBY GRANT A PERM T// �'��-� c
the am to hold temporarily and dres)
the body
yyn maker or persoryry having charge of co se) ,remove, or other ' dispose of [state ho )
` „4s< . ' 7 192w' (Signed) '
Dated_
t Local Regis rar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) is required.
Form VS. 61. (Rev. 6/63) (3A2.323)
ENDORSEMENT OF SEXT4)N OR PERSON IN CHARGE
OF PREMISES ON WHICH_� INTERMENTS QR
CREMATIO,�'I�S ARE MADE
Date of � " was 19 �•;�'
(Interment'or Cremation
(Nam of Cemetery, Crematorium, etc.)
WEjj Dfkvel��
Sr'r /P L / 3
Section 1 Lot No. Grave No.—
I
(Signed) "1
(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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict in which cemetery is located.
SEXTONS,FUNERAL DtRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAW FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.The law
will be enforced. Local Registzars are required, under penalty,
to report violations thereof.