Keyes, Francis Form vs.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 D RABLE BLACK INK. Town t - R
Di egi o—.....................
st.
pzver
Name o
Sex.... .., 't deceCasoeldor......... .. t .S orik
.divorced (wnte,t1F4y o rdfI
i Veteran
. ngle, married, widowed, street address)
(If an, give name of War)
Age (7 Yeard t) IonAhs j...;tr... .Days i e. ,140110--id---4,- s
, 7
Cause f D ath .
Certificate was signeOlby, ..1 s. M.D.
Address ..e5c;;:• • ../",;4
Place of Burial Removal).. ... .... I,7/
(If body is to be tei34@qtly held,fill in p e later
19 L-C6-
Cemetery ..„4„/..ef...-0,... (vte-er1—) Date of Burial.. ( '/'
(If body is to be te porarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for re 'strat' n aver rec rdedAitpinERmylLo ,, Record w. h the above stated Registered
Num and on th as' th l.rf r
.
Name) (Address)
the to hold tempor rily n the body.
Dated.
of. ker; person,Aing chargeottrpre) r, e ove,or se disnose (s how])
1 '.•Al 19.,,„ (Signed). . .. . . . v•
Local Registrar
This Pe .. t is sufficient for the Removal (and Interment or Cremation) of body to any part of the State ject to local
cemetery or ot.er 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 C�' .
Date 2-;;Ibir-i•-i w 7. 19`�
(Interment or
6/1:)' Z/;
Crie0.4,7 X("1
(Name of Cemetery, C matorlum, etc.)
Section Lot No.` 13B Grave No
(Signed) La,!v�� � ,.-- ,�'-���� `�►?L.1 C�.c,
(Person in charge)
Address_ ���-SC
Person in charge crust 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 OI m,NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.