Van Vranken, Jay Berm vs.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. .._:-_:!:-.
Village
Dist. No County...,:.,. z».. or City .........,,,
(It city, give street address)
Name of deceased _ Veteran f'1 G
Single, married, widowed, (IF veteran) give name of War) t
Sex Color or divorced (write the word).1(-( - Date of Death _ 19 J .6
Age Years Months Days Birthplace ,,...,..
Cause of Death [c•� ,, <f a. ,-. f.., .r "t �i `l1
i r ��� ��� n.Eti�/lsl
, l (t.{k-
Certificate was signed by , f j 1 r ( . .�./:F... t,er r'}-,(i4 b. 4�.M.D.
Address 1.,.. ' 7 --
Place of Burial (or Removal) .:.a k:.K.F `�1 (~-1' , /
(If body is to be temporarily held, fill in space later) _ .
Cemetery Date of Burial...(,..:..,.(.:./., .i...q. 19:...:..)
/
(If body is to be temporarily held,fill in space later) 1!
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 the basis thereof I HEREBY GRANT A PERMIT /.
to ...sr ` r;..r' ,;:1.�.... ..I". " t I• , /, �d;..t.C.-' X 6'--¢-".
(Name) (Address) /
the to hold temporarily and - c { -.. the body.
(Undertaker or person having charge of corpse) (Inter,remove,or otherwise dispose of [state how))
Dated 1 1.a.t. 19 (Signed)` I -,...�.r-J. J .s.�:.:.:.k ' 1-
(( r_ Local(' egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body tip 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) as required.
C 1
ec,I Cit..e
ENDORSEMENT OF SEXlUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
^-"+.--1- KlGt-C' 7 19�/Date of ./JZ' was
(Interment or Cremation)
/'2
✓mot. � -- ( :,-,---e...--
(Name of Cemetery, Crematorium, etc.
Section -J Lot No � Grave No.
(Signed) i" .., .�j'C'C'2'1�-C.�
(Person in charge)
Address e' r-zw _ C
,. .
�_. _,,,...,:,e,e.._, � ,
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 FFLE PERMIT WITHIN THREE
(3), DAYS with the Registrar Of District in which
cemetery is located.
r
SEXTONS, FUNERAL DIREC IRS and UNDERTAKERS
violating the law relative the return of permits
are liable to a penalty of FT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS!FOR THE FIRST OFFENSE.
The law will be enforced. al Registrars are re-
quired, under penalty, to rrt violations thereof.