Lanfear, Burney Farm O&aL NEW YORK STATE DEPARTMENT OF HEALTH
. OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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.__.;tii
r Village
Dist. No t.6-.county..."4 e(4, ✓! or City
pr
(If city, give street ad as)
___/2
Name of deceased...../. .., .t`L 1-'4----'-/ Clif Veteran
arT Single, married, widowed, c. n� (if veteran. give name of War)
SeX24.7 -Colon ... ..or divorced (write the word).. 'r',! Date f D ath Je 19-5
Age 7.6 'ears.... .M ths..yv - .Days Birth lac ../.. .%. . 4-4 . ..t. ..:�• 7
Cause of Death '!: H! € ..G%J ' 7 ' C i'�
Certificate was signedy� Gay r'L�,l/ M.D.
Gr 1 f
Address... ...: .. � ` ^
...
Place of Burial (or Removal) /jam-� „t�
(If body is to be,tgmporarily held,fill in space lat _,
Cemetery d // /.i ' Date of Burial. .c.'4 /r 19......r,--
(If body is to be temporar y ld,fill in space later)
Thn Certificate of Death containing the abo e 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 a ve stated Registered
Number, and on the basis th f HEREBY GRANT A PERMIT`S �� ,;
to ... : .. ...y= ,. ! f/ `c. 4'U tread // J!/�.I
the � ..., to hold tem orari and
P -Y:. - (Address) the body.
(u d tamer or person having charge o! rpse) _ (Inter`remove,LoalbRems-egistrarlse dispose of[s to how])
Dated r / (r:; 19'..r.�r (Signed) -,1,,,; '
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate (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
PREtiMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE )
-;.. /
Date of ( y. l was ;2-7 , 2:/ ig 4�.
(Interment or CreOon)
(Name of Cemetery, CCr�ematorium, etc.)
Section Lot No. _Grave No.
(Signed) , >/,- . > t
(Person in charge)
Address ri i `1r�� ''- 4'7e.. "„ � C_�
- -
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 crords
"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 OFN'1NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.