Vandenburg, Daisy Form VS.6I. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed ealy by the Local Registrar (Deputy or subresistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICAT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town , Registered No._ .Z
Village � z �-�sa Dist No 5 �°r County.._._.� v or City
, �Q (If city,give at dress)
i_i_ ...
Name o£,deceased... ... ... ...... Veteran
I. gle, married, widow (If vs we name of War)
Sex �— )K (write ) a-a-17..-a-�J Date of Death.... . . .. 7 19 `.) .,)
Age .Color.... r divorced the wor
... .Yea Months..�.... Da s Birth lace
Cause of De ....... . ... . .�•~'• 1?
Certificate was signed by M.D.
Address .1... ... . . ��/�
Place of Burial (or Rem• ..... i _
(If body is to be ter ora h I. in space 1st )
Cemetery ` `� ' v 6'.-7-nd .Date of Burial ..c 19 ` 2?
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particu r , having been presen d to'.--ire, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, ND SATISFACTORY AS REQUIRED BY LAW,
I hav' accepted the same or registration, have recorded it in my Local Record with the above stated Registered
Numir
,, on the base ereof I REBY GRANT A PERMIT
to . � s� �,N .'
—
�
the {v, to hold temporarily and `). ...k, L�� �-' the body.
(vitae }cle .ker o person h ving charge�r pas) (Inter,remove,' be. disnose eta owl)
Dated 1 ..... ' / 19...�1...t'S (Signed)
Local Registrar
This Pe I t is en"cient for the Removal (and Interment or Cremation) o y to any part of the State (subject t ocal
cemetery or •7.er regulations),unless removal is by common carrier, in which c a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX1ON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of i 2' was r_s ;>, y 19
(Interment or Cremation J
''- )z>if t
�s
ke ' _ a, z.:Z.(Name of Cemete y, Crematorium, etc.) /
Section Lot No. . Grave No
t
(Signed) l.L n.� s-�.y�� . r<i?G Lq
(Person in charge)
i
Address � 1. - �� . L4z - 6.--.-
Person in charge must return this PPz it 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.