Stanley, Howard Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tT 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. T ot� wn g Registered No.__.._...._....._._
Dist. No f�4L�...,lCour±ty L-j `''--'il- 't-4 ..ety ,
�� __ � ((�� (If city, give sir address)
Name of deceased.!'�7`// :je CO ,,('.`.,,Q.. Veteran
Sex2y� In le married, widowed, f (1 el an, Give name of War)
f Color..L.4.f or divorced (wnte the word)1 'v''`«d Date of a L �.,.r.,.......19.'I .�
Age.......h.�.q. Years '-{ Montlis.. ..`k�...........Days Birthplace - � �- ``1A a� -.!>e i....C'�
Cause of Death /a-,�I¢. � z-�la C -'? i,. `vY7 :j, 'C.� "z'.z
Certificate was signed by,4.}'1 t �4 .�-L `f J. .c;- fieZ4
l.• M.D.
Address /'� ice---:r%c--t—�-' /.... .. . .. .. .. � �
Place of Burial (or Removal) - ! 1,9'7'L.. 7
(If body is to b temporarily "1d,fill In apace later) y / //��
_Cemetery r i' �� ,_ (.,"-?Pi-c.2 . Date of Burial.. 4:. �3( 19- s"
(If body is to be temporarily/held,fill in spare 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
Nu bet, and on the basis tIkere9f I,HERE Y GRANT A PERMIT _r.e. zi
,,,,„..4--- ,Le".A" 7 e2e__E6, ---4-: c,
' �. �. � ddreaa)
t .e- {.. 4,,/t1.7kclame) to holdtemporarily and :'fir! .. the body.
( T q soning charge oic pse) (Inter,remote,orochoseo )Dated..... : '_1 19.. 1.. (Signed) —'z c-1 t -��d ..fix
LocalrRegistrar
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
Date of was QS, 3 / 19✓a
Interment or Cremation)
(Name of Cemetery, Crematorium,
ee..)-
r"fir
Section Lot No. Grave No.
(Signed) 02j2'tit
(Person in
;?L'tesnt
Address
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person.,,s in charge, the __,
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"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.