Smith, Vira Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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-21-a,
Dist. No6.Z.C72County....i.4.12,.0-C-4'11 Wage
or eitv ..).:.,-.Z..,LL,e..4t.;:i4:-.&e.C .--I
-.
, /7-e (If city, give street ad g
is
Name of deceased V "4"./..:-0,,,..„, e-1-----7-:-ZY-' -"e7:1.r--- Veteran ----cc/
Single, married, widowed,
Sex.k??..4/4. . oloitk.. '' .or divorced (write the word)..4ith."41,4 4, ( veteran. give name of War)
Date 2f_Aeath .4' .•-•.'L e?Al.1 7 19 1 15
Age.. .(1" „Years Lvt2nths „.. .... .Pays Bi place ...7 /c c C' yczo-,.
Cause of Death M:7.‘..-:-.g.k.1..C.4-2.'7 V'a 4..----e.0 4.4 /ALM*. F..... ".-Z.. - V-A44-241
• .7 •• ..• -.4.-. - •• • .....•• ••
Certificate was signedi
,-C J.,
,1---7
M.D.
Address ;! X47' ‘ a ‘r
Place of BuiiaL4or Removal) ' ...,:re,:-.2:-.Z...e- 7 /7',,_.,e_e. • -'---- ,
(If body is to mporarily 11 in space later)
Cemetery. ./.7.7.41:2:1.A. .,... ..e...e,Cr-.-4: ... .‘.-‘44...
/Death Date of Burial. . .4.--.-z. ....- - ` -:-.-zn 19.,.i.
(If body is to be temporari y h d,fill in space later)
The Certificate of containing the above tated particulars, having been p sented 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 recor ed it in my Local Record.with the above stated Registered
Numjier, aptkon the basis thereof F,./1.E 'i _
11277( .,,,<L. .‘.4.e:-. / ?.- ...-t - ' ,i .e'7
(A:rkA'e ie Z
the .i.Cereele. .4 4'. Lit ' to hold tempor : pand... .. ....<,-,..." .4.. .ez the body.
, ( ertaker or person havin charg ore) / (I its . minor aithRerwieg:trdarisn e of(state how])
Dated.... .. .4.0(‘‘ -,2-tv 19 ...> (Signed 1,,:e.--(7-7-.4-- --i------
Permit is sufficient for the Removal (and Interment or Cremation)A-o a y tio any part of the State (sobject to local
cemetery or other regulations), unless removal is by common carder, in which case 4 ranait Permit (VS No. 62) is required.
wit at.2.4
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date % was j, e 3-114 19
(Intersent or 6esShiisw)-
/2/ .)://1 (4,
4. (Nike of Cemetery: Crematorium, etc.) , •
Section 7 Lot No.32fr Grave No. —
(Signed) �`�,� �( 4-
(Person in c r
Address 'f' 11f)22
Person �chargemu t 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 THA;. FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.