Kirkpatrick, Robert Form VS.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. Town Registered No.__.._..`_°�_`.................._
Vilbge
Dist. No 5 L County. �.c�2,424 7.�:ck..:x or City ",�-4c-c-1-,�J .-,4,-2- '
........ ..
f/�i A . , / (If city.give street ddress)
Name of deceased i.29��"--C.�2 , /- .`..,...,A.,,,,,,,,e--4-e-r,,I:r,, Veteran —7.-.'.Z
� l Single, married, widowed, (lI vetarea, give name of wu>
.
Sex �774- Colort�.. i:. j..or divorced (write the word)... :J 2.2-6-4 �l- Date of Death I 19
Age 7 `' Years Months Day Birthplace.. :Zc: 1 yFzt .14
Cause of Death '7' 1 .. -C
Certificate was signed-b : t — � c- M.D.
Address V t_c--2*--,7, i1�„ .." �..1 -7-744, (. ' 2 .
Place of Burial (or Removal) ..:. .. .
/
(If body is to bs,temporarily held,fill in.space later) I
Cemetery.--..I 0-1-,,1-.1 , :f. l „.--.� C--e-1( 1.2.4 1-v Date of Burial 1— , • s 19
(If body is to be temporarily Geld, fill to space later)
The Certificate of Death containingGG the above stated partculars, 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 Loop' Record with the above stated Registered
Num and or. the ba is theregf t HEREBY GRANT A PERMIT C
to... 1 Lf)`��" ,� ��, /` ' ::...G:4: :l' --/X( ? 7, Ge.e" / 7'� G
,� ) (Address)
the 2 y � hold tempora and,�Z 1- Le the body.
( dertaker or person having charge pee) (Iot .,r ore,or otherwise dispose of [state how])
Dated.... :1i .2,'- ., 19..4? (Signed) j�*
...c..t-...z G- �k't7
L t/� 4y�Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate (.abject 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 was 3/ 19 4-
(Interment or Lion)
_/'V 7.?--e2-7'-'--—C-
Mame of Cemeter Crematorium etc
Y ��( r r )
Section Lot No. Grave No.
-7-
(Signed) _...>"; 0,-=-1.46 -7:. ,
---7"'e-
(Person in charge)
Address 4 (4/<=-�' '_,��i" ..l '_/�
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.