Herald, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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.
Re a 6
7111246,, /�gis�terso. C�
/
Dist. No. s C�' / County 6l�t^ Town,or City ..�C4`�"`
LL (If cityy, give street address)
Name of deceased tl//Ot . Veteran
✓✓✓ ( (If veteran, give name of War)
Single, married, widowed, �n ^ �
Sex or divorced (write the word) .G2ti Date of Death 19
Age ( ears ant s Day Birthplace /l - V,
Cause of Death�.�.Ce ...
Certificate was signed by ',. ri.......4e..t. M.D.
Address !Y�.. % ..
Place of Burial (or Removal) ..-. .(,P�(�✓1
(If body is to be temp rarily held, fil in space
Cemetery .. ..... Date of Burial (,2 -O 192
(If body is to he to el ,porarily fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion,, h recorded it(y my Local Record h the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
to C telC-2,_
2:
(Name) (A ,reSS
the to hold temporarily and the body
.
Dated ndertaker or pers�6tt�havin charge of cor7e3 (Int/ a emove, other a d' pose of (state how))
19 (Signed)
Locz1,Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a y part of t..c 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.
I"OItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date or C` `` ' ` was 1-` / 719 �\1
(Interment or-Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.