Allen, Harry Form vs.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 CERT ICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.?,
Village
Dist. No...4 1...County.. f� or City ..... ..s..� -
'�� (If city, give street address)
Name of deceased �( ‘;= 4-- Veteran '
�")-y, (If veteran, give name of War)
7� ngle, married, widowed, Gyzi / �A,,
Sex Color... . or divorced (write the word) / �-�/ Date of Death....�Cl 3 196
Age r Y ars oaths Days Birthplace.....�.ra Inc ,,...)2/
Cause of Death
Certificate was signe by 7.......4e -4--'2—
M,D.
AddressL37- 9 37 fr.-
Place of Burial r Removal) 1) t ( � .
(If body 1s to be arily held,-111 in spa later) l/
Cemetery �..4:1(�:.J( -et - r�z • Date of Burial 77¢Yz'-' Sr 19 G V
(If body Is to be temporarily held,fill in space later)
Thq 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 SATISFAC!'ORY 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 basis ereof I HEREBY GRANT A PERMIT
to /Mr ,., 44.4 �y
ams) (Addres
the to hold temporarily and the body.
(Undertaker or person having charge of corpse) (Inter,rem ve,or otherwise dispose of(state howl)
Dated .4j, : : t.... 19>%z.y. (Signed) .��
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date
(Interment or Creme ion)
_ `y '
(Name of Cemetery, Crematorium, etc.)
Section 7;7+.3 Lot No. ,4 T ?Crave No. l
(Signed)
(Person in.Cha/ L(
Address
Person in charge Deist 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," asd 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.