Stark, Hazel Form VS.IL. 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 Primacy 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.__..1.!�"�
`` �j� Village
-7C2 rt-tom
Dist. No..��tG( County.........!'! -`�It''Z) or City -�f�< .L
�n �*-7� (If city, give street address)
Name of deceased.. a- 7/ �.:L.1L Veteran '-d'
7 / 'Single, married, widowed, (I( veteran. give name of Wet)
Sex.... . .: �Q4Color..d or divorced (write the word) Date of Dea /.. ..../.Ni"."-- . 19.S..
Age .cS Years. .. Months .01,.1�.1 .Days . .. Birthplace...,,.. •�...r...
Cause of Death :r...:.. sue' `'.-. .,....,.. .. ...ti: ,:,.e4. : --y.......
Certificate was signed by ,. Crv.., M.D.
Address / 4 '
•
Place of Burial (or Removal) /ijf.. ... . .
(If body 1s to be temporarll_Meld,911 la pace later) ��
Cemetery --z,H� e u-
,i-d. -rrh ' Date o Burial / / $ 19
(If body is to be temporarily held,Ill in space 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
Number, and/on the basis thereof•I HEREBY GRANT A PERMIT OC
the -'2��' �- -_-) (Address) /
" - :,.. to hold temporarily and. the body.
(Undertaker or rsoa having charge of corpse) _....SJI.irr,re ♦e,or of wise dispose of[state how])
Dated 1 1...E 19..5.4. (Signed)
Local Registrar
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
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
t _
)
Date of -er r:; was i 1,4� 19 l_j
(Interment or'rriemn#Pon)
/i ( y a,.rJ / /
(Name of Cemetery, Crematorium, etc.)
If 12.
Section Z. 2 2 Lot No. / { Grave No.
11
(Signed) ('_' .. l._, c>7. 4"
(Person in charge)
Address i 1r�1�c !.c.,. +. lIr t�, u_
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 wards
"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.