Boyd, Bruce Form v&6- 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 No4a..2.�..._.........
� Village �� '
Dist. No County...».....�. GF�:. !.... or City ..-4. l`€fk..\
(If city,give strect.address) arch-,"....,-
Name of deceased.....(F...i7 ice....... ... ...:?,4.-l.S..... 4... Veteran ...1 P.1 X
p. Single, married, widowed, _ (If vet e els�.,ive name of War)
Sex Color. or or divorced (write the word).... .... .... Date of Death ///h,,5 19..57
Age • , Year . Months .,...DDa s ��( Birthplace
g s(` .Y
Cause of Death - .... . . .. ... ..»....
Certificate was signed b �����.. �fiLS..c M.D.
Address cff�" . .... ....
Place of Burial ( r Removal) / :...... ..�..... �%'Y ,f ? ' '
(If body is to be tee rarily held,rill in space_I ter) vv
Cemetery f .....� .. `' �i�.., Date of Burialr�r 19
(If body is to be temporarily held,dli 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 ccepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbelr, and on the basi thfEREBY GRANT A PERMIT � (� i 4
'c to —
(Address)
1
the to hold temporari:y and " the body.
(Undertaker or pe ha g charge of corpse) t rem o .nose of tate how])
Dated - /gt.. 19.:.1:7 (Signed) ,,._
' al
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (.abject to local
cen•etary or other regulations), unless removal is by common car.ier, in which case a Transit Permit (VS No. 62) le required.
ENDORSEMENT OF SEX'iUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date 9;, -'l�ll/.-L was . -ec C 195
(Interment orem)
/I? "
�— 9�c� • LL.-c
(Name of Cemetery, Crematorium, etc. •
Section Lot No../g/l Grave No. /
(person in charge)
Address � -G
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 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.