Van Lent, Baby Boy Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 URABLE BLACK INK. Town Registered
No.W ...
Village
Dist. Nod'of Coun .. 445P4•1400,r
(If city,gives ddress)
Na of deceased... �• . Veteran
Ingle, iff ed, widowed, teran, slue n e of War)
Sex ...Color or divorc-• (write the word)...,. ....... Date of '.': r.�11 0�/
Age Years Month . .. ..._.....D. . ,Birthplace. Jr. ,8.•r .. ••.,y•
Cause of Death...6#�h. �rp) . ;
Certificate was sign ./.t7,, ,.(, M.D. y
Address �. .. 'n.. l'�
Place of Burial (or Removal) . ' ,..n..i... .-
t �iy
(If body Is to Dora- • d,11 in space later) // 19 .P"'
Cemetery be - a Date of B rice... t•.l.� V
(If body is to be temporarily • d,d11 in space later)
The Certificate of Dea . 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 • ve accepted the same for registration, hav orded it in my Lora ecord with e abovs{tated Registered
N,r, , • on the syh� ere f I RA PERMI ���S /"Vr
(Name) ` ddress)
the ,•,• „ o hold temporarily and,..,... the body.
,ndertaker or moon raring charge aL ) i re,o se dig Ist
of ats Low))
Dated'.. ... .. .... //. 19..4 � (Signed)
esistrce
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),sinless removal is by common currier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 44:L/ was : GJ 19 f
(Interment or Cremation)
(Name of emeter Crcmetorium, etc.)
*-4,, AA-64— - 3 •
Section Lot No. Grave No.
(Signed) C A G j`
(Person in charge)
Address J . /64`( 62=0„,
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.