Burnett, Lena Form o8.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fa 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._ Cr C.C.
Village fL,z-,. 4
Dist. No County... Y. or City
(If city, give street address)
Name of deceased >.> V1.ft7.r• CI ..4l'. 4r Veteran
14 7 Single, married, widowed, •j:j/ r (If vet ssn. give name of Was)
Sex y Color ..1....or divorced (write the word).. L Date of Death ....<,-: /s3 19TS'
Age Year Months Days Birthplace
Cause of Death -� i;: -
�.Certificate was signed by ilk.7 ......� rt.IL
rs.., M.D.
Address ` ?...,:;t`G...:..-.7
-7`!
Place of Burial (or Removal) '^.—
(If body is to be teIporarilyy held, fill in space late —
Cemetery 9 “-*:...k... Date of rial / e//�(/...I..j 19..'C/
..ace. ... /
(It body I.to be temporarily held, fill in space later)
The Certificate of Death containing the above sated 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
Number, and on the basis thereof .I HEREBY GRANT A PERMIT
the ...x .' 1 >. a
to hold temporarily and (, ' ,�' the body.
(Undertake�jyr person having charge of corpse) (Inter,remo or Dtb sells di f[ howl
Dated l.l� �7 i9 • ~ (Signed) .��� �.
This Permit is sufficient for the Removal Registrar
(and Interment o; Cremation) o a y 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 CITATIONS
ARE MADE
Date,:oe Li was __% f / r�•� '
� v
(Interment or"E4l C1 )
l T
(Name of Cemetery, Crematorium, e.)
Section f'/ Lot No./ Y 6 r Grave No. Z�
/ ('
(Signed) .-.2n,/
(Person in charge)
kidress
/24-./ /;'"Z(;;)</)-
< '/ C<<--ee G .
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.