Hubert, Arthur Form VS.at- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
AT Thie 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 WRI•ITEN IN DURABLE BLACK INK. Town Registered No. ,.?..'1 la
...11 ,tT�adel t..� Villa (,9
Dist. i6'1 County. or C'
ri (If city, give street address)
al Yly Veteran #19--
(Name of :.ceased �a... -
Single, married, widowed, ` I( vetgive name of War)
Sex 1(1..... olor VI/ or divorced (write th word)....,._...1! 440-.d = of Dea A195C'
Age ,3z 4 Months... ,.. . Dav ei�
Cause of Death ... .. ... �.
Certificate was signed by M.D.
Address 1. ,
Place of Burial (or Remov
(If body I.to temporarily hel 1.1n space 1 e /( t
Cemete temporarily
..,. . 'vw.1.. D to of rial 1 �1 19
ry...
(if body la to be temporarily eld, flit in apace later) .
The.Certificate of Dea containing the above a ed particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, ORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ed the same for istration, have recorded it in my Local Record with the above stated Registered
Number, on the bag th REBYT GRANT A PERMIT i /J _ 4- ��% 0 ra41:1,,
to V r
the ` to hold temporarily and , the body.
(Untie is o3 Ifs n hying charge of rpae) (in • reta;,ve, j %the (se disnose of(state howl)
Dated l./.C�i Y 19 4 f,- (Signed) •
This Permit is sufficient for the Removal (and Interment or Cremation) of a • ny t of the State (subject to local
cemetery or other regulations),unless removal is by common currier, in which case a s ransit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PRFMI'SES ON WHICH INTEIMINTS OR CREMATIONS
ARE MADE (�`cC;,[.c: (-'6)( (C
Date of ,.- was :-:-'- 19 �''
(Interment orsmY1lea)
fe1 ?L ,fC:',,�'Zt
. ' . ( Ye( Z , , s
(N}'me or Cemetery, Crematorium, etc.),
Section Lot No. Grave No.
(Signed) /J! ,, / ' ( -- li ,',‘.i I l_C
(person in charge)
Address (I- ( C j�/ -(-' '" (('. _ *�. 1
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 STAT ;°
MENT, write across the face of the Permit the words `^4;a
"No person in charge," and FILE PERMIT WITHIN THREE R`, `
(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.