Bentley, Charles form VS al NEW YORK. STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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.._:"L__
Village
Dist. No L,S County or City _./..:- .-e.e-2-ti�
U (If city, give street address)
7
Name of deceased (--`L'"f` / (-, �� � r 'Z Veteran
' Single, married, widowed, (If veteran. -give name of War)
Sex 4;..CoIorV�'' or divorced (wnte the word).,. ... .. ..... .... Date of D timid/ 2r 19.-
Age 7 Years I Months 7 7 Days Birthplace.:. .*...,. I., ,�7
Cause of Death ,---4,..c4.s$:dA/ ' lu . i. —xr s- ( h:: .:6:i.a`ct..- . ........:� :,,ct.4 •-.A.4'A.- -- -e,,"
Certificate was signed 3)y...7i+ . .:^rk.::4r:i f.- - _ '�4-4— / I" M.D.
Address.... .7..4 "-ter $. ..:r. �'"�" ivi, -UG .:.../... `r`•Y
Place of Burial (or Removal) I f, j t: :4,l:Lc—
(If body is to 4 temporarily held,fill In space later)
Cemetery r!ul,t �/�/ . .�� 11�'.. .. .r.({� Date of Burial 'I< � / 19
(if body is to be temporarYiy ld, fill 1n 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
Num , and on th as' ereof I HEREBY GRANT A PERMIT ,-- / - s
to / ..f -Z � � . . . .._. : 4. z..l.-... .,�
" (Address)
the `,C�!/(i . . . to hold ten;porari)y and the b dy.
(tnr taker or person having charge of erpae) (Int ,remove or twigs dlsnoee of[stab how])
Dated .t7 ( 19....5.. . (Signed) ' :.:<..c.... ..........G.2...-.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of .I�to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Ttanait Permit (VS No. 62) is required.
vier
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PRE4fISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of261 was / 19✓r
(Interment or Ciraeom)/j)
(Name of Cemetery, Crematorium, etc.)
Section ,7 Lot No.to(a / Grave No. /
(Signed) C12
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(Person in charg
•
Address " +J
Person in charge Rust 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.