Green, Yetta Form vs.s>r NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q This Permit can be signed oaly by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FLUNG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._.:.. 4;.&....._-
/ ✓7. 1. Village �J /
Dist. No "S�r ( County.....................:r !I't- or City ''�✓�� '�Y`` C- '
A (If city,give street address)
Name of deceased ` .. �� 1� Veteran
I. Single, married, widowed, (1f veteran. give name of War)
Sex Color.../? or divorced (wnte the word). ;r��Y�4 Date of Death: . /G .' 19
Age `7.Z. Years Months _ ............Days Birthplace L.:Y --J---f--x:
Cause of Death ...c: 4. :n, ...... a. .-Z a.. . a•/(.
Certificate was signed by ,4a d.4.{ (-(;,, .7. 1. M.D.
Address .: -. } . .,4.-�-' I. .
Place of Burial (or Removal) �
y ..,c.:.,4.e. st...•.: •;
(If body is to be temporarily held,fill in space later)
Cemetery _,,..* x..c::.•C:,,444 Date of Burial 19
(If body is to be temporarily held, fill h f 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,;and on the basis theregf I HEREBY GRAIIIT A PERMIT = , f'-
4 d 7- 1 17
to...•.• ,.i..,.
(Name) —
(Address)
the the body.
..,, .,.:;.,. ;..G:::.:.0 to hold temporarily and - . � •-•
(Undertaker person having charge of corpse) (Inter,remove o befWi ooa owl)
Dated ��tl 19 (Signed) Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of to any part of the State (object to local
cemetery or other regulations),unless removal is by common carrier, in which c e 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 V "0.:S2' nJ was IC J I 19 S 7
(Interment or or Cremation)
•
7"1 0. Lt./04A/
(Nametpt Cemetery, Crematorium, tc.)
Section Lot No. Grave No.
.(Signed)
(Person in charm)
Address ,r .,, '` , ,� 0r �
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fram above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MST HIGN 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.