King, Clifford Form vs.st. 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
t IINN DURABLE BLACK INK. T Registered No._._.._ _ _
.Q.
.... ........
Village
Dist. No...�. .. .Conn
(If c!ty, give street. ss)
Name of decease •....• •.. ..... . .(3'4t ,.. Veteran
eteran, sive name of War)
i le, married, widowed,
Sex\A..1LColor. or divorced ord)�A to of Dea �,..�. ...,...19. .
Age. x rs on �i� ..Days Birth c7 i.(
'
Cause of Death.. ... -
.. �, w,
Certificate was si a by - • D.
Addy ( ) •�,�
Place o ri or Remo 1 : v�.
(If body o be temporarily - Lk
fill In spar later)
Date of Burl l F
(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 I.o ecord with the above state a istered
umber, n the basis tke" �I .REBY NT A PERMIT
-
cziscisi
to. a ...
1 Name (A.• s)
the • N`'� • o hold to Sly and.. .... the body.
dertaker or person haying charge of corpse) (Inter,rem oth nose of ` • ))
Dat ,,, (...L(. 195 (Signe •
Local 111
'
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (wabje- to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
L Q- ( >ic_e -
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
) /F
•Date of '-9 Z&�- 7' was % ----aC/7 19
(Interment or Chem)
r ? ( 7 /-
(Name of Cemetery, Crematorium, etc.)
,
Section .-�2-� Lot No. ) Grave No.
: -
(signed) "2-e-L'z-- `�- v 621— `�
(Person in charge)
Address -1 '-.--i .� VI.'
Cep � �
Person in charge must return this Permit
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.