Bain, Harold Form vs.et NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit can be signed only by the Leal 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 SLACK INK Town
RegisteredN o _ : .
Village r"Dist No 3-6-6/County . � I_ ,;:._ or itt
(If city,give street address)
Name of deceased Wa--2 -.-(.2 . 2".....,6.r. .?t.. Veteran LZrt-cry
/LI Single, married, w1 owed, `� (If voter�*r give name of War)
Sex r 2-4 Color.,,% or divorced (write the word)....Z�1' Date of D atth.. :....................f f
Age 7:. ..Years Months Days I�i place.... .
Cause of Death. ... x---
Certificate was signed by. . . ... .... M.D.
Address ,� :�,?...... . .7. •AZi
Place of Burial (or Removal) -2..v.. .Y. .. ...
.
(If body is to be tom arily held,fill!n space 1atie r)
Cemetery .7 S Date of Burial r�. 19..../
(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 acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basis thereof/ Y GRANT A PERMIT /jO / y/
/7/4.. ��r r (Address)
the .�?` to hold temporan.y and.... the body.
(Undertt or Aeon having charge of corpse) (Inter,remove,or otherwise dispose of [state how])
Dated .s' 19.,5 (Signed) Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (snbjeet to local
rt^n:aary or other regulations), unless removal Is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSFAtENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date "- - was ' J 19L5
(Interment or"ad o)
;ZAZ..i472 ?„st
(Name o Cemetery, Crematorium, .)
Ci
Section ` Lot No. • Grave No. '
/-7
(Signed)
(person in charge)
Address 1, L�a r k/-4 �--1Y- 7. , .
Person in charge Dust 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.