Munson, Leroy Form vg.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit cam be signed only by the Local Registrar (Deputy or subregiatrar) 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._ t5
^ ' Village Town of Kingsbury
Dist. No.....5.262 County.. isreinton
... °......_ or City
LeR p j R. l�un s on (IL city, give street address)
NoName of deceased Veteran
°��1 :Ihite Single, married, widowed, Iv rried (If Sept,give 19561 name of 9
Sex ' i e Color or divorced (wnte the word) Date of Death19
Age ' Years Months Days Birthplace Glens FaU,1i., 'rYs
Cause of Death kaere ro 7asclilar emmorbao
Certificate was signed by C. V. �a�imer M.D.
Address 'ud.s on ?all s,. T.Y.
Place of Burial (or Removal) alleen, teivry,,,,.Wp.r ;en„County
(If body 1s to be teeffirofriryib,sipl,fill in sppacV atterr)
Cemetery Date of Burial 4ept 6.m
(If body is to be temporarily held,fill 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 t�>� Eirl� ' t�f Iz EREBY GRANT A PERMIT Hudson ?al 1 s s IT T.
to
(Name) (Address)
the jhi d2x.t ker to hold temporarily and inter the body.
(Under `er r n ha chary corpse) (Inter,re r otherwise 1 )
Dated ep`�e�m$°�ro' 19 (Signed)
enut
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
Hate ?L 6 l was rl� �t, 19 '
(Interment or Cr )
G c< C t j> t� l``
(Name of Cemetery, Crematorium, etc.)
Section '� Lot No. Grave No.
(Signed) �l'•yC •
(Person in charge)
=id.dress
4-1
Person in charge mist 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.