Esmond, Robert Form OB.aL NEW YORK STATE DEPARTMENT OF HEALTH ' (- r 7� O
OFFICIAL BURIAL (OR REMOVAL) PERMIT
__ 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 ;rt2
Village
Dist. Nob . L.County.... ..... mil' 1i1»xY .r or City =-'
. ..
I �.- (If city,give street address)
Name of deceased Veteran -¢—'
�^ f�, Single, married, widowed, (lf •fi,an• give name of War) ry
Sex "J Color..., or divorced (wnte the word).. . Date of D ath (-- 4 F.- 19.. .Age 7/ Year Months ....... Days Birthplace. ? 7. d-c �xrra.�.1�.._ . )
Cause of Death . Lrt... .... V
Certificate was signed by �f.'! ' : , M.D.
Address % . 7j
27 Y
Place of Burial (or Removal) �! / ,Y'.... ^i�c��k �t�.- �
(If body is to be tempjarily held, flu in-apace later) r /
Cemetery fiaa..4. .�•• 4... Ce Date of Burial £,! $3 U 19 j'
(If body is to be temporarily held,fill 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
Numben and on the bad' f I HEREBY GRANT A PERMIT j� �,
to .G:.o�C� .rfi,,,...:' ' .21-yl�~.a,e...n.�--)' V C'-'e-'G.--�....;!
(Na ms) (Address)
the .'�F-0-- to hold temporari:y and. the body.
(Untie r or person having ehargs of corpse) (In o e r he moose a state how])
Dated - -2.2 19.4: (Signed) toe egirtrar.. ...�
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 car-irr, in which case a Transit Permit (VS No. 62) it, required.
<-=evo¢-e. L c Q1 ci.eJ(t)
ENDORSEIENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date tip was ��c'3 d 19 CS
(Intent onmeele
V
(Name o Cemetery, Cre..t.riue, etc.)
��
Section Lot No. Ur�f Grave No. 2
(Signed) ' ?;LJ 7,-.:_ (1%400:74Z
Peron in cluing.)
• �Address
Person in charge oust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frctn above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE,
RENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAIS 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.