Superenant, Claire For'VS.sL 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
Town _ Registered No.__..�._ ._......._
Village /�(�J
Dist. No' County or City --
(If city, give street address)
Name of deceased...c,r - '• , ` y Veteran
< Single, married, w (If velejaq.give name of Wax)
I`T Color ► C or divorced (write the word)..?Y.. .4:441..f Date of Death „r" 19J ‘
Age Years. . ..Months %..Days Birthplacea.%f r+ri.X..-.,. 7
Cause of Death - . c.�_ , / -
Certificate was signed by CA., LLD.• M.D.
Address ," ...7
Place of Burial (or Removal) c-a...,i 1t„ -K?�7
(If body Is to bp� temporarily held, fill in■ ce-latex}----
Cemetery. ./ , - ,-v Date of Burial ti-cy 19
--
Of body is to be temporarily held, nil 1n space later)
The.Certificate of Death containing the above st ted 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 Rec d with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT _ J .
tom ; . .hdf .,.f.
ss
Na (A .
the ..::z .., .:z_.. to hold temporarily and .. the body.
(Undertaa er or person having charge of corpse) 1.1:,.,er_er,or erwise dls ose of [state bowl)
Dated `" 19 (Signed), Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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
44eDate of 'y t-r r-ti_ � was . l 19•f t'
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. _Grave No.
(Signed) ,-/C_A -eif
Pr/
erson in charge)
Address I d y 6 0 0 - -1-(1
A-L7.
Person in charge Deist 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.