Thomas, Minnie Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
S! 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 F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town istered No.
081/ fVahh..�C.4. Village ( Q
Dist. No County or City Q
(If city, give street address)
Name f deceased73 a !ate Veteran
y, Single, married, widowed, (If eran, ive name of Was)
Sex A..Colorl.!.1� ,i.or divorced (wnte the word) /V't'0Q'�'w`P'` Date of Death lg✓-�
Age...,,'J Ye rs `T,-R G'ths o .Days , Birthplac / -e4-1-'9 ,.
Cause of Death w ,
Certificate was signed by 1 mot'»• ...._.r........ ..M.D.
Address -..
Place of Burial (or Removal) / 'v'T't ��
(If body is to kelemposarlly hep fill in apace IaCgr� .^
Cemetery... i ' '� �l � Date of Burial 19�
(If body is to be temporarily held,fill in apace later)
Thq Certificate of Death containing the above stated particulars, having been Ares nted 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 sta d Registered
Number on e "ill, thetegl� GRANT A PERMIT /i4 _ ' ./Giz to 4,HEREBY
`� �L *,
•
the to hold temporarily and the body.
(j.c4..L..
rtakor person hayng charge of corpse) (Inter,rem of o1 se di a state how])
Dated ...... •a•? 19 _ - (Signed) Local Registrar
This, mit is sufficient for the Removal (and Interment or Cremation) of is'cgdy to any pert of the 'fate (ea..j 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 ?tC- was 19,-6",-3
61.1t:s.:.t o )
(Name of Cemetery, Crematofium, etc.)
Section 7 Lot No. / g/ Grave No. 3'
(Signed0z /` ' V(eezt -
(Person in "Charge)
i
Address l L)Ytit � 2 27/
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.