Hams, Baby Boy B Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit eau be signed only by the Local Registrar (Deputy or aubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICy4TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No. .w�..-
S4 G Village
Dist. No ` 1 County..._..........&::»rt.:.... or City �t� ,2, ,- '7,cc .,f.
! �/ ir (If city, give street address)
Name of deceased Cc , Y.. �? ��L:e� Veteran
bj��/!�Sirlgle, marr l�widowed, (If veteran. give name of War)
Sex kthColor../.7. .f�t.Cor divorced (write the word)...%� ''Li:e Date of Death sue. ....�....19
/`
Age Years.........�R,R.......Nlonths ..,::..._...Days Birthplace k,� � .e+.... ..9./
Cause of Death ' " ''-",P— � - T '� t
Certificate was signed by a<...�f ?L. ' ��'! r✓.I M.D.
Address ' .. ,....
Place of Burial (or Removal) .. .� sy� ) `fr
(If body is to be temp rarily held,fill.in space later) - !/ '
Cemetery � .. r_..r Date of Burial . - /..3 19
(If body is to be temporarily Id, fill 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
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to 4 .. 4.. ,. % -�-p... ..4 ;:.. .)
1N7ame) , �C__ (Address)
the / to hold temporarily and LT__
the body.
(Undertaker or;person having charge of corpse) Titer,remove r otherq}se dispose of [state how])
Dated ....,! 19..i..( (Signed) C�- A��.d`Sit
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the date (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 PhESON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
sj
j
Date of ; c 1 t t- _
""7' was _t t , °-:5 19 .) 7{
(Interment or Cremation)
(Name of Cemetery, Cremetorts(M, etc.)
Section Lot No. Grave No.
(Signed) 6 )1 (C1
(Person in charge)
Address G t�--'7 uz _ .. ,`� /� �/.0
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.