Reid, Charles Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 _.ci....._
Village +
Dist. No..y.Z:.S.�..Couaty...j,L.}�'c,.z.:�.�,rt:x or City ec�-.:>.._.�te.�tyy'
T.
(If city, give strut address)
Name of deceased....��'i, y,, �,,�.G: "� ��J e.e_,(,:c, Veteran / rV i,
Single, married, widowed, (If veteran, give name of War)
Sex...., =Color..WA/.Z..or divorced (write the word).....kl/1(A#/q Date of Death � , E 19A
Age „g7. Years., Mon ................».
�� �� Days B;rth lact� ..`'✓Ji� .
Cause of Death a�i� .E✓Z rail, (! ,.. 4. .
Certificate. was sign .t�i) "�� 2�l.:".. . . . d • M.D.
Address...l.7. 41.t�t� S..J.., .� � L::! t
Place of Burial (or Removal) d':,,.Z.. .2.t=.24.1. °j"
(If body 1e to be teyiporartly held fill pace Inter) /�
Cemetery / 6:2:k.1--7 " ,,,-4 6.y.�.u:.?:;? ` Date of Burial c . 7�1 19..E
(If body hi to be temporarily hel ,fill i space later)
Thq Certificate of Death containing the above stated pa ticulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, COR ECT, 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
Num and on thebasis ereof I }IE GRANT A PERMIT
to f)G..l, .. Kali c-"4�...r:....._... .1.. ti, w�.1�,-..- .1V 4 h- 7
the r L.t,. 4C�'.�. -e ) ddress) /
`ZL..4,p, to hold tempora ' y and ,. 7--z .r... .z•--) me body.
(Undertaker or perrAllaring cbkrge rpse) ,r (Infr,rertore, herwile disnose of Is is bow))
Dated 'k/ 19.,� (Signed)...i:..., �� :: "c 2/l'LL.
This Permit is sufficient for the RemovalJ ai Registrar
ofz
(and Interment or Cremation) of a y ny part the State (wbject to local
cemetery or other regulations),unless removal is by common carrier, in which case a TransitPermit (VS No. 62) is required.
( -2c
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREsdATIONS
ARE MADE
Date of /` `(� '^y► 19�
(Interment or )
:72
(Naas o3 Cemetery, Cr matoriun, etc.)
ction Lot No. Grave No. G/
(Signed
(person in charge)
Address
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.