Diregrman, Harriet Form F&s'. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit can be signed ealy 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 SLACK INK. Town �,. U i Registered No C
��/' Village ]�Wi
Dist. No County...... l. L or City �aG��
�Q • (If city, give street address)
Name of deceased � `"! / -��'�� Veteran
Single, married widowed, (if veteran. Iva name of War)
Sex ,.:.Color (.4/ or divorced (write the word) ``" L' Date of eath. /�y,l 19 5
Age '�..5 Years j Mont,9Is Days Birthplace 'ul"dw2l...q.y.
Cause of Death �`�`'L ..�..t.v--L :u... //
Certificate was signed by . ../ >p ce' /��j� �n M.D.
Address 1 3 .C,..... { c,t L' a.L� - .`! 1
Place of Burial (or Removal) j c�-'4 ��'�Y'" C` ``"`.--4 -� 4*.
(If body 1s to hetemporarily held, fill space later)Cemetery <�.�.1. t``"`� / Date of Burial 19(If body is to be temporarily 1 Id,fill in space Ifter)
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 saute for registration, have recorded it in my Local Record with the above statedt Registered
Numb, and.on the basis thereof I HEREBY GRANT A PERMIT (c /(i r 11 /
to .:f��. .LA iL <S. (i�,' (_t;,`i G Al:.,, .......
ame)
the Lr..4./..t: f (ea----- - -----' to hold tempo,,raarily and . .:4� the body.
(tined rtgker or person having eharge_ corpse) , ( (Inter,re7ove, r erwiee dispose of[state how])
(/ / -
Dated.........�.....� ` 19..h (Signed) . . v.--
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (.abject 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 SEXTON OR PERRKIN IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRI•MATIONS
ARE MADE
Date was 7 19
(Interment or.Cteiaticn)
s
e
drew of Cemetery, Crematorium, etc.)
•
Section ` Lot No3.5Grave No.V'
(Signed)
(parson in charge)
,dress
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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 WITHIM 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.