Keech, Albert Form vs.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr This Permit eau be signed may 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._-Z,..
�' p' .... ��st1
Dist. No County--...��'r2t
. . or City -�/
�j (If city, give street address)
Name of deceased.... /. ".:..... . .. rc Veteran �' '`''
�. f� yj,�/,! Single, mar , widowed, C�'?,? (If scan. give name of War)
Sex.. . . 44.Color. . . . ..or divorced (write the word).... . Date of Death.... . /" c 19S r
Age... . De Yeas. Mopth� ,�...�Daays Bir i,,lace.. a7� 1tg .
Cause of Death ; , Ce l
Certificate was signed by �.,•4- ..„7,-. �� M.D.
b.
Addressa ... . .... y ....:
Place of Burial Removal) ,, :.ur...:fial
,(If body is to be •, '•,rily held,8)3 in space later) _Cemetery �..�Lrkrc... I it-cam d Dateof // 19 S 1�
(If body is to be temporarily held,fill in space later)
The;Certificate of Death containing the above stated particulars, having been presen ed to m , 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
Number,*don as th� �EREBY GRANT A PERMIT �/� �p
/ // ) ^— (Address)
the G-1:• • • •• ••• •••••• to hold temporarily and the body.
(Underta or pe baring charge of corpse) (Int rem ye,or Oyeririse di ose of(state how])
Dated ... . . it. 19 "�'' (Signed)
Local Registrar
This Pe it is su dent 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 required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o -;?c- Z-2/ / was (rely // 190
(Interment or )U
/
(Name of Cemetery, Crematorium, etc.)
Section '2- Lot No. � Grave No.
(Sighed) � � .: >_C.-6'
(Person in charge)
Address gi-1*-z _ 411, 74-4 "97• _/.
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.