Rerenau, Meyer form VS.M. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No...
/ . Village L
Dist. No.S7..f 5-County. ...... . . 1.��.I+•. et Cif ill ff'
(If city, give street address)
Name of deceased X. - Veteran
Sine, married, widowed, (If veteran, give Caine of Wax)
Sex �' A..i,..Color -%�as or divorced (wnte the word- , Date of Death ......1.. 19 4 45
Age Years Months ‘ Da I Birthplace
Cause of Death , .
Certificate was signed by '4 M.D.
Address n
. .. .. .....
e .
.,, i
Place of Burial (or Removal) t .P.•4,, ,,,,`Ill.. • ..
(If body le to be temporarily held,fill is later 4
Cemetery c�, '� � .�1., Date of Burial.. . Zi. 19.ri4
(If body is to be temporarily held,fi 1 in space e
ThA 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
Nu , and on the kris thereof I H REBY GRANT A PERMIT - (fin ,�
kt(Name) Q.�-� (Address) •
the •► to hold temporarily and f'I�•���++ the body.
gndgr�ater o rson basing charge,ef corpse) ,(Inter,r m e,or o iwk..1dit ose of [state how])
Dated r a. 19..f ..r (Signed) , '
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 carrier, in which case a Transit Permit (VS No. 62) is regteircd,
ENDORSEMENT OF SEXTON OR POISON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
dv‘..otri_44....
Date of ... was Li) 19
(Interment or Cremation)
41
Th yt
Itrtg--
(Name of Ceme ry, Crematorium, etc.)
Section Lot No. _Grave No.
(Si ged) ` ''N-'�nn.:> / r' .k
(Person iTn charge)
�AdCI.I'eSS J G il�1,�.i�•�`r v L'S .�N"/ ""bar
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.