Jones, Cathy Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W This Permit can be signed only by the Local Registrar (Deputy or subregistrer) 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 R ' tared No._............,........�
/ �•• f' / n " Village / - - ../fi -7/2../Zi
Dist. No..l.. .. or City
(If city• e street add s)
Name of deceased0..44.444.4, Veteran
. .. .
Single arried, widowed, (If 744' a acme of War)
-� 'q g
Sex t Color fl1J • or divorced (write the word)..... .. . .... .. � Date o •�1•l • ••••���
Age - Its i M s says, ' Birth .. . /... .y
Cause of Death—. �, ... ••. •.
Certificate was signed by. 0• �• M.D.
Address .%I? ... ... .
Place of Burin (or Removal)
(If body is to to Dorartly he 1 in ace ater) •+� �^
Cemetery.... ,,,.d..%Ls,. •• -�"`�*•� • Date of Burial ".l s� 19- 2S
(If body is to be temporarily held,511 In space later)
Thn 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 hav accepted the same for re ' tration, have recorded iit in my Local Record with the above stag egistered
Nu , and on the basis HEREBY GRANT A PERMIT c
to.. .. k:�;c:.� ..: 4-' _ .f:.r.�0 -�5... .. i .. ..... � ? •
the ....... . .• .....to hold temporaf�''� t•-0 the body.
(Undertake r po Arming chi ojeprpse) 0 a• reml .or o • reef dig jests
Dated (. — / c. 1 ..:d" (Sired) 4-- dr �, ••C�L .X�
Local Registrar . .4
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the state (eubjeet to local
cemetery or other regulations),unless removal Is by common carrier, in which case a Transit Permit (VS No. 62) is required.
C
•
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o Z7L / was '( 19
(Interment or Gmamo i,Vm�
sae of Cemetery, Crematorium, etc.)
Section Lct No7,12- Grave No
(Signed) /.?,r LI c��rv((
(Person n dkfirge)
Addres , 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 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.