Cochran, Samuel Form VS.gl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can Is• 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.6 . ...‘.:-../
Wine
Dist No --- 6-I County a...,-./4:sa. or City ..e.C:r.,.,ea--e. '- -,
4d.er-f---- ---...,............ C-ii./i.. ..-- 7-.//1 (If city, give street addreas)
Name of deceased....
Veteran
4;4- Single, married, widowed, • . (if veteran, give name of War)
Sex.?.1.4 .-ColorlA or divorced (wnte the word) ...... ..... .. .- Date of Death'-- - c-7 ';''. 19
Age ,5"-‘) Ysors .I Monthsr". — .Day ,. Birthplace - ii..-i:-.- / 7./ '(
i
Cause of Death t-CL-7<-c----ka "3- .7
Certificate was signed by.,-.." , 7, --r-S.-‘:--eS'T.r- M.D.
Address ' / e:- - fe 'T -- 7-gc
Place of Burial (or Removal) .'--1 ‘-` -- •--.1-:-.Z.111-K-7-al-- --Alt..."
(If body ig to be_temporarfly 14,..,,Illl in space later)
Cemetery .i, - 2-1 / (1-7,,,d,-..-(r,e.e..-4.:Z .,c-.-e.ly
Date of Burial6-- 2- 19
(If body is to be temporarily bel 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 hav accepted the same for egistration, have recorded it in my Local Record with the above stated Registered
Number, and op the basis f I HEREBY GRANT A PERMIT. - -
,
---72 ` .* ,„ ,, /' ii-e. f/. 17
r
.41fr(Jaldress)
th ..• a /
e
to hold temporarily and ..,,,,...etel-GeL-64,----- the body.
34dertaker or rsont4reng ehargecorpee) fey (Inter,remo_vg...or otherwise(Hawse of [state bow])
Dated. "--e---' i 19..3.. • (Signed),. - /- -t7•.-k,..-722! • 1,--r .
,4- Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any past of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ra.nsit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR P tSON IN CHARGE OF
PREIfI'SES ON WHICH INTERMENITS OR CREMATIONS
ARE MADE Crort.
Date 19
(Interment or
(Name of Cemetery, rematorium, etc.)
7
Section Lot No.. /7 Grave No.7
(Signed)
cie,>T
(Person in charge)
Address !r` G 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.