Hay, Everett Form V8.sI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 > Registered No.__.._
Dist. No1 .r. [ County.A l_ .. age 5 u :, �
r
(If city, give address)
Name of deceased fie : e�k . .. ...>t% //, Veteran
gingle, married, wi.. r J
(if veteran, give name of war)
Se ...Color7.'Z r divorced (write a s %'� Date of eath..t�y / 19'�
Age .t�...Yef•s .g Months... „..D s place ,.. e:a ..
Cause of Death. .... .. . . �i 14 ` . .- /.J .......�4 �2.... . . Wit ,
Certificate was signed by �,.. OP , ,,, ���� . M.D.
Address i. fi. . -. .€);�
Place of Burial (or Removal) yi ,af. -, : -4--_i
(If body is to be tem�prarily held, fill lfrUy- la
Cemetery -' �.. '. .,�,' 19'• ,.
....� K. t:� Date of Burial.... -
(If body is to be temporarily held, fill In ep . ate
The Certificate of Death cont in .. • the ove stated particulars, having been presented to me, after careful exami-
nation, the same appearing oo a- COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same_Ldr;-registration, have recorded it in my Local Record with the above stated Registered
Number and on the bass thereof I HEREBY GRANT A PERMIT
to ' .e .:..,f ... . ... . -+ -- y
Ina) (Address)
the .c:c ,......e...t to hold temporarily and,: .: the body.
(LJjAertaker person having charge of,, rpse) (Inter, more,or therwise¢lsoose of[state bow])
/Dated... ,EC ✓r/ 7 19t, (Signed) ....//.... ,,,. .:.�. G.Il" {
/ .ocai 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 o- 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
Irate o - was /7e / 19
(Interment or eEemriLon)
Xfr Z.";
(Name of Cemetery, Crematorium, etc )
Section ;7 Lot No. 23 75 Grave No. f
(Signed)
(Person in elfarge)
dress
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
RENT, 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.