Prothero, Joseph Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr This Permit can be signed only ley the Local Registrar (Deputy or subregiatrar) 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 SLACK INK. Town Registered No.__.._...._........_;.._.._
Village
Dist. No...J........„County or City
(If city, give Street address)
Name of deceased —7- .(-(1. Veteran
--) � Single, married, widowed, J (If veteran, give name of War)
Sex 11 Color or divorced (write the word).. Date of Death 19
Age Years Months _ Days Birthplace
/
Cause of Death :=�-r- '
Certificate was signed by (— M.D.
Address -
Place of Burial (or Removal) ; 't
(If body is to be temporarily held,fill in space later)
Cemetery. ..... ...-.?is. a.. ,.:...:cc.. ..:.F:17 Date of Burial ' 19
(If body is to be temporarily held, fill in 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 the basis thereof. ;I IEREBY GRANT A PERMIT /
(Name) (Address)
theme to hold temporarily nd the body.
(Undertaker or person having charge of corpse) (Inter, r ove eyme oom of(state howl)
Dated 19 (Signed
Local Regirtrar
This Permit is sufficient for the Removal (and Interment or Crematio ) of a body to any past of the Mats (subject to local
cox:-+eery or other regulations),unless removal is by common carrier, in wh case a Transit Permit (VS No. 62) is required.
L..G,.e.,f,(......v...„
ENDORSEMENT OF S1X1UN OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
•
Date of,' %l Zwas j -51 i 19
(Interment or Cremation)
t(ifame of Cemetery, Crematorium, etc.)
•
Section -.-12---‘Lotlo: L L4drave No. 62
(Signed �:— -' C`..�,.1.— l.-( ',Y;774 ,:,.
(Person in charge)
' Address L.0 ' V 7 - ! 4._
--d � 7 . .
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 UNLiERTAKERS
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.