Lewis, Mary Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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. TownRegistered No._
u i A -Vi1 arg--e—
Dist No.k.S.........County.1 Ckiv1/4-9-(017:44.411 or City
(If city-, give street addres
Name of deceased b• -4....414,)-(-0 Veteran
(If eteran give name of War)
, ._
Single, ma *ed, widowed,
Sex".1.1:9:!WNI,_,,. Color ...,,,. r divorc wnte e . . . Date of psith OpAje L 4....10 -7
Age .Years I onths - .Days Birthplace. .
Cause of Death
Certificate was signed by
Address .1
Place of Burial (or Removal \..)) ......
(If body is to be tento.raril he d, 1 in p later)
Cemetery Date of Burial - 0 19"-6,2
(If body is to be temporarily held,fill In ace later)
The Certificate of Death contai g the above stated p iculars, 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 ba • the f HEREBY GRANT A PERM T P
to d. -Ariv-e-,A-0 to
(Address)
the holtem d porarily and. \
the body.
(Linde ker or pe n bps:ing cbarge of corpse) n ,rem , r othe 1so [s orr])
Dated kN1/4. 19.1, (Signed) .,5
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) iti#4ody to any part of the (subject to local
cemetery or 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 of -- { ;h,c �t,- ` _`
wass.. 1�. t'
(Interment or Cremation)
(Name of Ceme Crematorium, etc.)
Section \--v., Lot No. Grave No.
(Signed) J4-0-1A)"ef.
tL6:�'L4— : 1
(Person in charge)
Address ?'
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 cords
"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.