Davidson, Walter Form VS.6L 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town egistered No._.._...._............
Dist. Noh. Village....Counry.::S.:S�����.... �r City ---r--z----e--c -e,
(If city, give street
Name of deceased.. (d/ Veteran -..'
Single, married, widowed, f/ (If ve era of a, give name War)
Sex/l+ ...Coloele..a.
.� ...or divorced (wnte the word)'S-€44, (c Date_9f_Death..,G 6_,....444.‘ 19. ��'
i ..P.)//4„,_
Age..../ Years ..Months Days � Birthplace.i. •fir y .. .
/
Cause of Death -
Certificate was signed by ,
Address r..� _ r M.D.
Place of Burial or Removal) ` �
. .. . . ... ..
(If body is to be orari] held,fill I pace )p I JJJJJJ
Cemetery ::.x:: ... .. ate of Burial.... 2 7 19 i �'
(If body is to be temporarily held,fill I 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 a basis thereof I,. IEREBY GRANT A PERMIT / � - .'
2'`‘.:9-4.ei
(Name) 4 r' Address) i....» . ..r[ ,
the i I. .... ( / to hold tempor ril and e body.
aln'a e pe r aving charge of rpse) (Inter,remove, anomie of let9,tef w])
Dated...yti /: s{7�.{ i9.. .,7`; (Signed) �' "t4 r : .! !r C
Local 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 INTERMENTS OR CREMATIONS
ARE MADE
Date of �2- f'.,��...- wdc`5'" 2 1 19 C...5-6
(Interment or.4reaetfon)
A � //T
COJ CJ 1 a: LG?i-c^e"
(Na of CImetery, Crematorium, etc.)
Section Lot No. Grave No.
Q '(Signed) ,Jl -r 1
(Person in charge)
Address / if- L/C
Person in charge must return this Permit
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 fiords
"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 OPri.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.