Clements, Roswell Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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 IN DURABLE BLACK INK Town Registered No._./..k.2. ._
jj Village �� Ci� 1 ...L�
Dist. No...J...42.Cf.County.... :��ll�..�.s.:): or City
(If city. give street address)
Name of deceased K4 ... Veteran —.
Single, married, widowed, A (If veteran. tab, name of War)
Sex Color s or divorced (write the word) i� 4. 4-Date of De th. - �? 19.:c
Age Year Months.. ._.. . .. l Birthplace .. .. ... �a••.. L.I
Cause of Death L - 7....
Certificate was signed by .....».... .• .... ..P..7rlii4�
.D.
Address
Place of Burial ( Removal) � Z: l. . .
(If body is to be tem rily held,yle,space later)
Cemetery.........,,,, ..�.�i.Lo C4 '.-44 Dane o Burinl ‘��'- 19 .
(If body is to be temporarily held,nil in space later)
Thq 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 a cepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num on the basiyile ,O REBY GRANT A PERMIT , Gj
e) (Address)
the . . fi � • to hold temporari.y and..N.... ... the body.
havi Inter,rem ,or of dispose of [state how])
(Undertaker or pe g eharp of corpse)
Dated x -�..2.- 19. (Signed)..:--=- / L 7.//-,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sesbject to local
4:en-,terry or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) required.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PRH1I SES ON WHICH INTETMENTS OR CREMATIONS
ARE MADE
Date 2..;) -1-y1.:, ° /// / .y� 19 //' 1
(Inter.ent or -1.-r
/ . ,
(21:11..r-
.---(......:--e-Z-2-7,1_.....6.-ilt---7
(Mane of Cemetery, Crenat.riun, etc.) I
®/ 4-ii.::::,`'"'`"`�`-e`J-
Section t Lot No//4., Grave No�
a /� ► ��
(Si gne ��L'.i��,��34`�'a-v ��»«JJ G�-P'1"'
(person in ckars.)
Address , f ./IIY_,Q ,7
,X4641-°‘Person in charge Dust return this Permit to �e
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 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 FIRlST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.