Brown, George Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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.__..3......iV ._
' ' I City 0,
Dist. Nc. �`.d.,t..County........W.G1.1lt:�+ or City ?^'c'•'�
.''nn __ (If city, give street address)
Name of ..eceased !Wk ( V. . .... Veteran )v.*
Li J,, Sing , marYed, widowed, , • Of vNersn. give name of Wax)
.Sex. . . Q Color...:. t:'+'11....or divorced (write the word t`n,"Y! of ea 4 1 4' X 7 19
Age Years Mon s....... ...... »...Days i ir> : . ce... .`. ... . �
Cause of Death ��1 .�'i.a. I`��� a� , - , U
Certificate was signed by ek4�� � �. .D.A � M.D.
Address y-LAA4
Place of Burial (or Remov 1) rows-, 4Q........ .. . . . . �//���,(��//,
(If body is to be tear ari}y h 821 in space later) V /C /_
Cemetery hAAP V ' ' 19 ��
(If body is to be temporarily held,811 in space later)
Th4 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 the basis thereof HEREBY GRANT A PERMIT
(Nae) (address)
the to hold temporarily and
the body.
(Una t�a�ke�r jr person having charge corpse) (In remo)e,or erwise di ose of [state howl)
Dated �T' ,Z, 19..6 (Signed)
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 -,-. . �t N 1,42
Date of _r�L ,-iv_ ^1 was t�- �J? J-
(Interment or Creme-Man
.� 1
L�
(Nome of Cemetery, Crematorium, e tn.)
G:
Sect ion ---"' Lot No: C Grave No. f •
G'
(Signed) 1'"4%-.e+� CV Or:v.)Z /' ,.
(person in charge) (�(
Address ' r 1. 66101114—
- ,_es —�
Person in charge Est return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF 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.