Hanchett, Fred Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registratica District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIIICATE OF
K DEATH, LEGIBLY WRITTEN IN DURABLE BLACK IN Town Registered No._._ .Q...q
/ VillageDist. i` N 4 .1..County...P ^ or City
I/ (It city, give street address)
4
Name o ceased .�....G. . Veteran
rr,�_- 0 :,� Single, married, widowed, (If ve an,
�live name of War)
Sex.J..\ ,.•.. olor..��W"I . n..or divorced (w e the word) (, = of Death.....ii !/ 19..`S...
Age 1 .1.- Years �t....,.....Mo ths.. ... ..... .....Da_v` e ..�'ZRA4./
Cause of Death ,Asx,141A,f�t. CA —
Certificate was signed by kw... . i4. ..1.�...)14..o.•: l+ ...w *. M.D
Address .... ..... n
Place of Burial (or Removal) c I er ' CL.�.!N ' Tom'` •••(If body is to byp�t�empor rily . d,fill in a ac I er)Cemetery....Lou ..' , Date of11-4414A.411144/11'....:J.
urial j 19 0
(If body is to be temporarily •ld, fill in s ace later)
The Certificate of Den containing the above stated particulars, having been presented to e, 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
�,thh0e,,above stated Registered
Number,
��and
��on the bash t•�• •f I HEREBY GRANT A PERMIT " "
to 1.Qkl2/.2.. ... .... A.. V44
...
(Name) Address)
the to hold temporarily and . . . the body.
(U dertake9r or person having charge corpse) lotg�, re •e,or of erwise dlmose of [state bow])
Dated 19.. p (Signed)
��...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo to any past of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a :,ranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE C24-„-c :. !J!l Ze-
Date was'. /V 19
(Interment or 'Cremation)
(Name of Ceme tery, Crematorium, etc.)
•
Section Lot No. Grave No.
(Signed) /-".`<<i%' ( ! 22
(Person in charge)
Address (
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.