Fitzgerald, Katherine Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
n 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
Town Registered No.__..�f��'
Village
Dist. No ��U County... ��-,� �s�-� or City--��--yyr-- r (If city, give street address)
Name of deceased (Y _ .S:c,s ah.e : .. Z Veteran --`s)
�/ Single, married, wI d, • (If vet an, give name of Wu)
Sex " - Color IV, or divorced (wnte e word) 4-1-4=rwr-A Date of Death a"" 0 0 19,r6
Age............1 ..Years., 7...Month�-7Days Birthplace.... ' .: .. J
Cause of De th ,�,./ �—.
Certificate was signed by CfT. , v7 p D.
Address irk---. ..�Q,t -- �7t�'-- 7f
Place of Burial (or Removal) "--
(If body 1s to b mporp ily held,fil sp t r
Cemetery P�4P......f:?..i1—' cam- D to of Burial V-' 19..-.57‘,
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the a o ,e stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPL TE, 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, on the b sys' reof I HEREBY GRANT A PERMIT c�
to #/
�,. . .Na - 2.
r /
the to hold temporarily and .r the body.
nderta r or person having charge orpse) Inter, remove„gr otherwise isnose of [state how])
Dated `' / 19 Ll b (Signed) A. •""t
Local Registrar
This Pe is sufficient for the Removal (and Interment or Cremation) of a body to any past 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
C(/4 41,
Date of_ n/ �� I
� 19
(Interment or Cremation
)
/ 7L. T
(Name of Cemetery, Cremgltorium, etc.)
Section Lot No. Grave No.
(signed) „77/,i4-6'-_t4- _ Y.ft ) 1(
(Person in charge)
r i /
Address/.. B �/ -%Zi �� , U y
Person in charge Heist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in c}T'arge, 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 OI hNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.