Svedgal, Harry Form VS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
girThfa 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 Z. i Registered No...
Viitage
Dist. No.. County. �� �`�u orry =t 1,.°c • 4 1.1s...N
....... ....
ll (If city, give street ad es)
Name of deceased YV9ngle, ma ' ,
. v E.Q.. ., Veteran
I . widowed, (If veteran, give name of War
Sex Color w or divorced wnte the word) ,.Dot 1 < < 19
Age/c ,.... ears -Months s Birthplace.. ..... ...
Cause of Death....
Certificate was e byA.A,A. �4r4 M.D.
.. . . ..... ..
Addres •
. . . . ........ .... .............. . ... ..... .... ...
Place of Burial (or R oval) '
(If bod be temporarily fill sp a dater)
Cemete .. Cam,ct
Date of Burial 01/ 1 (e=°
(If body is to be temporarily held, 811 in ace later)
The Certificate of Death contai ing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISF 'TOR.Y A REQUIRED BY LAW,
I have accepted the same for re ' tion, have recorded it in my Local R co d with the above stated Re ' tered
Nu , and o the basis t f BY GIN aE
to.. .. fL.... 'gR� �'"
(Name) dress)
th to hold to t�•+ F ly and t. the bo
( dertaker or person having charge ) (Inter, remove,o of s ['state ho
�.L''!0 t �,,...19 fib' . (Signet Ilk.... �-'
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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRE1ATIONS
ARE MADE
Date of i av' 1'`?. j.'. was �.i;-u' l A) 19 S C-
(Interment or Cremation)
i :�
`
- — N , Uwe of beme es tort e ...L
n
Section L 1o. _Grave No.
(Signed) �� t' 1 .ry
(Person 11 arge)
0,..Address /1 9` Lc'i '� k.l't.'1 ' 3` 'A t""
i
4,
Person in charge narst i turn this Permit to
the Registrar of his Dist< '.tt.within SEVEN (7) DAYS
from above date. If no p' ;;,.oft is in charge, the
FUNERAL DIRECTOR or UNDER '�y�,,MUST SIGN ABOVE STATE
1 V'T'`" trite ati ' 3 e
"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.