Hall, David Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILIN and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.
r , Village ` 1e ---�^
Dist. No Googly...» �'{."»`L:.:�: .,* or City G • t
Y
• , f p }If�city, give street address)
Name of deceased Xi �'�-t"'' �.. -7- l� - - 5,...- eteran
j Single, married, wid ���
OE v teran, give name of War)
Sex.. . Color or divorced wnte elword)l1"� -�' Date of Death 4 19
Age 4.1 Year ... Months ..Days Birthplace
Cause of Death 4—/ s-e* ..,
Certificate was signed by — J M.D.
Address
Place of Burial (or Removal) . �` :. - -
Cemetery.. � <- .„... ,:,..�..E .. '. z'K:C.....�.,(, . Date of Buria .. S.e'� 19
(If body is to be porarlly held fill Dace at
(If body is to be temp arily held,fill In op ce r)The Certificate of Death containi ,g'the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be; OMPLETE, 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
Nu n t to b ' ' th ' I I I-JEREBY GRANT A PERMIT/ `
�/ 1
t0... r 7
)
dregs)
the - ; to hold temporarily andK. --e—I -x-� the body.
j�yynderta�k�ev�or person havf g charge of corpse) f' /f (Inter,remove,or otherwise di nose of[state howl)
Dated..Cei .'i.1�K� ---- 19 ....0 (Signed) l
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
h7Ltor /f)
C
/A l �
///1 � n*fir�� f
(Naga ./s/gi Cemetery, Crematorium, etc.
Section Lot No. 74 Grave No.
(Sided) 5L6.
(Person if'ch ge)
•
Address •
697
Person in charge gust 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 wards
"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.