Thomas, Leroy Form o8.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
o' 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. Tewn Registered No....' -3
Dist. No� ..
}.1 Count),\J Vi '__ i+ . ?
�'� Q � (If city,give street address)
Name of deceased '—b\. . .�� \\ ''tea Veteran 4T'
o \ Sing married, widowed, (If veteran. give name of war)
Sex lYV�A -...Col o or divorced (wn the word..% Date of Deat�I` Z 1
Age <,\ Years M the Days Birthplacet,1,1 .... —.N\.
Cause of Death ,. . .. .
Certificate was signed by �iX..,. •
M.D.
Address - '
Place of Burial (or Removal) �.N.. • `c
(If body 1s to be temporkriky,hel 11 in space later) ,
Cemetery ...k` , . .. Nn.-). • Date of Burin . . .. % a 19�V\
(If body is to be temporarily hei , 1 in space later)
Th4 Certificate of Death containing the above stated particulars, having been presence to' e, 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
Nu , and on the basis thereof I HEREBY GRANT A PERMIT
Nams) Y (Address) �l
the to hold tem orarily and ,... the body.
( ertaker or person having charge of corpse) (Int re o� or oth se dlroose of[stab Dow))
Dated %.k 195`\ (Signed) � .\� ..:
Local Registrar
This Permit is su ent for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery o- 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
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o ‘4.t - was �-C-` Y 19 .S 7
(Interment or Crept tion) /9
(Name of Cem tery, Crematorium, etc.)
Section �- Lot No. Grave `�' '
(Signed) (-t(A ✓ (ICJ
(Person in charge)
Address , 4 . 0 a
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.