Hammond, Arthur Form vs.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Rir This Permit tan 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._4. 4
r ' �� � / Village
Dist. No Al U County..._.,�1.�!����lXlt�ll or City ?1,04
jam— (I1 city, glue street�es)
Name of deceased 1 . Veteran "�
• Single, married, widowed, (If veteran, give nameof Wa
r ��//
Sex...44. Color . ,.or ivorc writ the word) Date of D ath...... .. .. .. ' Et 19,5..,l2.
Age .r• Years... .Days Birthplace y9,-4�1.. Q
Cause of Death 1'. . . . .litr'
Certificate was signed by M.D.
Address ^''
Place of Burial (or Removal) —1 44.n1.. o.
(If body is to be 4e}npprar11y theid,fill 1n s e later) ll
Cemetery L ).t ... 6:9•410 Date of Burial / 0 19 J
(If body is to be emporarily held, fill in space later)
Thft Certificate of Death containing the above stated particulars, having been presented t 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
Nul;ber and iionnn the baa' thereof I HEREBY GRANT A PERMIT k n�
to 1 ,I[�ll., NLsr,�. (saarea.)
the bod .
-.).1-4f"
the . . to hold temporarily and � Y
( ertater or non having charge Toque) (Ina ,re e,or oth se dispose of [state how])
Dated..:. �..11 / C 19. ., nrp (Signed) Local es-litre:
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Slate (wibject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT T OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERME4TS OR CREMATIONS
ARE MADE
Date of .'l.. C c was( //G f //C 19 !_(`+
(Interment or.:Cs. .tjgn).-
(Name of Cemetery, Crematorium, etc.) //
Section 1 9 Lot No.- / ? Grave No. r/
(Signed) 71:4:6„.4.( s( e e)
(Person in charge)
Address (C cl C - ? �(7.
Person in charge oust 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
violatii.: 'be 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 enfo.ced. Local Registrars are re-
quired, under penalty, to report violations thereof.