Thomson, Accuath Form OB.aL NEW YORK STATE DEPARTMENT OF HEALTH .7_5
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Cir 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 CERTIF'1ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town t. Registered No.
(r! °% �y ,�,u,4-" Village f�.
Dist No-� Coua or City �; '�,'-, N�1`C."
(If city, give street address)
Name of deceased 0 isfY`--, Veteran
Sexiiyy ,,/ Single, married, widowed, i c><ti�c.� t(I et , give name of War)
; . ....ColOer or divorced (wnte the word f v Date of ath.. ..: -'z'G 19 'IA
Age.....4 Years... — .,Months Days Birthplace tipi.- AT,
Cause of Death CA -�. h �-i.` GZ.cct. u-' -
Certificate was signed by t/} �' M.D.
Address �,,. ,... ,. �✓� �a�`�-�Place of Burial (or Removal) .�. i--c-��0- q ,
(If body Is to be-tempo arily/�ld�fill In space later)
Cemeteryiki.7- 44.-rr, <,4.c,� l l l� 19..u'...y�
t,1�' `� Date of Burs ..... ....
(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
Number n the 'ba the I HEREBY GRANT A PERMIT J/, ,, -
t0 4 CRC .4
the 44.121-4 .1c..) (Address) `)to hold temporarily and the body.
r or 4erson haying chargegt, ) (I a remoye� snore o slats Low))
Dated... - a19 , z (Signed)•
t al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (wabject to local
cemetery or other regulations),unless 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 INTERME1tiTS OR CITATIONS
ARE BADE 6 L ii e-
Date 1 j was //
f�/ \ 19/ 7
• (Interment or C/ematlon)
4 f /jam _ a' , '
(Name of Cemetery, Crematorium, etc.) s' 1
'Section /1 Lot No. Grave No k a
(Signed) �~ ( i41‘:"-:- C_G7-:•1-
(Person in charge)
' � ,, s �lC � �Cy1
Address b -/ /C//k 2'
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.