Merritt, George Form VS.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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:c .. .1.County.. . 2 a'21 or City -, :....4.. - cc.: e-
(If city, Bice stret address)
Name of deceased : -c: 'l Veteran -2zz,f
• Single, married, widowed, Of v erin give name of War)
Sex �1� Color or divorced (write the word) -1')"-1-< ei Date of D th C'.c `.-,.2 :.3 9S
Age Yearir - .. _.Months .- ..... ..Days Birthplace...T.. :7.:-2.:r1..:G�i.. .,2).....))
Cause f Death 44?"Z:i..c..‘-..1 z" /- 1Y6;j1 .:t,l- : :
Certificate was signed by �:7 „C. .. .a.----- M.D.
Address . F . .�. 2‘
Place of Burial kor,Removal ..... .
i? 7
(If body U to be tam or rile held,Au 1 apace inter)r �j�
Cemetery ,. n..n.s.. A�.,.- ,c - Date of Burial .c. .6, 19..5f-
(If body is to be temporarily held,811 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 frtd o the basis thereof I HEREBY c " iNT A PERMIT
to .X..y.,4.4 .l.G..,.Z2.e.... -4 f.l.S.l..,..L.. l4.1„.o i 4..:11..+f ��� I
a�n.) f (Address)
the t.�� e(e4:1...t,/ .t..i.- to hold tempo 'ly d..... ... .. the body.
(Underts or person having charge of corpse) (Inter,rove. d .ose of[stab how])
Dated (. L.tit-' �...- 19.:$.g- (Signed) V:c.. c-'' ,-�4`- . is
/� Local Registrar
This Permit is 'fufficient for the Removal (and Interment or Crematio of a body to any part of the Mate (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ec'7Zti 4, _
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o 19
(Interment or Cr tinny
(Name of Cemetery, Crematorium, d
Section -"-� Lot No \r-/ Grave No. ---5)
(Sided) //. 2e1-,-,51..-t-,_... . ; i /cer2. [
(Person in charge)
Address " 1 ,.�..,.
,,(2.:0.., -,_,,a_.e...
,<27 .
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.