Robichard, Baby Boy Form Ts.6- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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._--_. _S
CI
Iu Village (�%/fJ _ G'C.4! ll../
Dist. No ....County--... .. .1'X YL.d or City ,,��srl,.Z,�....4
y.
�� ( f city,81ve street address)
Name of deceased 4,3 �� ... .••.». .. . . . • Veteran
ald, d (If vet • give name of War)
Sex Color....?(/f' Si on •iveo,rcedmarrie
(writhete owe wo,rd).. i .....� '?.'XDate of D ... ..../.[F19.: .,
Age ' Ye , Months Days Birthplace ..•� ,•y•..
Cause of Death..... ........ .. .. ..... f
Certificate was signed by ? f . -1. .. M.D.
Address �,✓ . Y......?„..7 .
Place of Burial (o emoval) Q Irtl�'J � r v:..
(If body is to be tem or y held, in,.ptce bter) s
Cemetery K4/4...,,,....li.. .L.4....:w L Date of Burial h�
fill ,(•.ec.-•• %.••f..19... `"d°'v
(If body is to be tern orarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, of er 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, on e basis thereof HEREBY GRANT A PERMIT )
to . .1.:{i..ul IL" a Y kA..k lr a�.. ... /.?�46 1 .r 7
(Address)
the • to hold temporarily and e body.
(Uncle e or person ha charge at corps.) (Inter,remove, th anose f a howl)
Dated ....../i1 19 ;.1..' / (Signed)
r al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a y to any part of the State (subject to local
C't. dry or other regulations),unless removal is by common earlier, in which age a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTER1MENTS OR CREMATIONS
ARE MADE
Date 2>i,�.� 1,ra ^/ 19(6-7
(Interment or oty)
Ley
z-lam /
( aloe or Cemetery, Crematorium, etc
Sectiar4 ► Grave No?/A.
(Signed)
(parson in carp)
Address �.�t�L.� �C/• Cw.�` J
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER WJBT 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.