Chadwick, Alton Form TS.al. NEW YORK STATE DEPARTMENT OF HEALTH !c >3
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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 DURAB- BLACK INK Town Regi d No._ ..
// Village
Dist. No:i .k.U.f County.. .......402 "l...... or City
(If city,give street address)
Name deceased .. . .. . ..;. .. Veteran
(lf vefer give acme of Wax)
Single, married, widowed,
S ......... ..Color:. ..... .or divorced (wnte the word). ...Date of Death.. X,4 ./7..19
7(3 Year .
Ageoaths Days Birthplace .... ... . ..
Cause of Death..
Certificate was sign bi� ,. • M.D.
Address.... .:....
Place of Burial ( r Removal) . . . . ... .. .. ...
(If body is to be to rarll held, in
ce later) //
Cemetery �' " - Date of Burial..072-..9,(A ,7 19
(If body is to be temporarily held,fill n 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 registrati , have recorded it in my Local Recor with the above stated Registered
Nu , on the a ' f I REBY GRANT A PERMIT ' �y
to. .. a. .. ' '7•P
if dress)
the to hold temporarily and •4P
(Um tter or a baring charge of corpse) Icy f rwise dlsnole of[state howl/he body.
Dated'... .. ..: 47 19 (Signed) �Or-#.- i ./,/W.,, � :e "
/ Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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 INTERMEdTS OR CREMATIONS
ARE MADE j ca -
Date AEI ' 19 L3
(Interment or Creme ion)
)
(N of emetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in charge
Address
Person in charge Trust return thi 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 wards
"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 OFLYNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.