Barker, Harold Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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.__.6...y
Village
Dist. I`'o..•(1 0° 1 County 141PV1-"Ad" or City 09.0444Da
Q , f3 (If city, give street address)
Name of deceased �� - `-� V Veteran (,i/ C Jr-
'I , Q� ,f1• Single, married, widowed, jA, (If veteran, give name of war)
Sex..104.-.W..�:(..Color'� ?""'�i or divorced (write the word) Yt'4 AMA Date of Death �4— 1 S 19.
Age +rl. Years R.., ...Months 1.5. .Day Birthplace
Cause of Death Q
Certificate was signed by M.D.
. .A., M.D.
Address �K,(J,�.4 V
Place of Burial (or Removal) retk h- 06....ru~1..-64.Ama. h i
(If body is to be to M.ortr1]y a dt fill in space later) ,
Cemetery..,.,..... .t... . 24 r J Date of Burial 1...' 19.. lo
(If body is to be temporarily held, 1111 In 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
Number and on the basis thereof I HEREBY GRANT A PERMIT
to l.e[URA,� K.,...
Name) (Address)
the to hold temporarily and the body.
a rta er or person having charge corpse) ( h Inter, remove,or ot n e lse dis a of [state howl)
Dated - /7 19.k.. (Signed) �j�. �d
(/ `Local mistral'
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat 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
PROMISES ON WHICH INTERMENTS OR CROJATIONS
ARE MADE
Date of- •)c `C e-a),c ,- was✓ .14 19 l
(Interment or Cremation)
I-) ---) ' d yr---' '
(Name of Cemetery, Crematorium, Etc.)
C
Section a2. 2 Lot No. //1 Grave No.
(Signed) i%C>..-,a G[ >ke e-", )1 ( l:
(Person in charge)
Address •r� f L lj' /•c'
Person in charge must 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.