Bessaw, Henry Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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. Th- Registered No._..'2 0 9
Village
Dist. No.. ;G ( County........W '.. Rrt4 or City
�^ (If city, give street ad so
Name of deceased l.Y! �a44)--- Veteran /v4
Sin e, married, widowed, t�i eleran. give name of Wu)
Sex hA. Color w_ or divorced (write the word) Date of D th.. .. . .. . /0 195
Age ` 5 Years oaths 31.:Y...D Birthplace.../
Cause of Death .. Q. .
Certificate was signed by 1 M.D.
Address 1
Place of Burial (or Removal) � kj.....`� '
(If body le to be temporarily h d,fill in safe later3
Cemetery r. ' I U4- 4/ Date of Burial r 3 194.7.4.—
(If body is to be temporarily held,Ell in space later)
The 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
Num , an�d ��PP,�, the basis th f I HEREBY GRANT A PERMIT (�Q� xif
to GV4lrK� .I�..,...� __Am
, )(ail
the tNams) to hold temporarily and /} (Addreee) the body.
(U dertaker or person haying charge of co ) (I r,r mov ,or
ootthh�" se dleoose of(state bow])
Dated 1. 19...4. (Signed)
Local Registrar
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the 'fate (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 ofj22 t X. - 19
(Interment or Qm)
dz-5,7,1___Je4-gy"
(Name or Cemetery, Cremetorlm6t, etc.)
Section Lot No. Grave No.
(Signed) �:ice„� �, V1 1,.- !
(Person In charge)
Address (�.'G�G'0)0 '1.)$1.4- "' .2 (4A-7
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.