Chandler, Suel Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q This Permit can be signed ealy by the Lecal Registrar (Deputy or subregistrar) of the Printery Registration District (Town,
Village, or City) in which the death occurred attar the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._..__..4_.
Village Dist. No County - - or City -d
(If city, give street address)
Name of deceased - /..C' Veteran
Single, married, widowed, �_ (If veteran, give name of War)
Sex Color / , or divorced (write the word) �6 r' Date of Death 19
Age Year` Months Days / Birthplace
Cause of Death : 'f
Certificate was signed by - M.D.„,
Address ...Jr `.,
Place of Burial (or Removal) .t.i.
(If body Is to be temporarily held,fill in space later) '
i i
Cemetery . 1. Date of Burial /1,!` 19......
(If body is to be temporarily held, fill In space later)
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 same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereofI HEREBY GRANT A PERMIT )) /
to C.:' :.".t:...a -w: �-. »............... l G
(Name) (Address)
the / e. .Y.0.:...4 to hold temporarily and - the body.
(And k r or person having charge of corpse) (Inter,remove,or otherwise dispose of[state howl)
Dated :ks..::..(....�" 19...•..... (Signed) --:-
Local Registrar
Thie it is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (estbject 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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
Date of was lg �S
(In te risen t lorapsemsw!®n)
/2/ (.
(Name of Cemetery, Crematorium, etc.)
-C
/ 7
9
Section Lot No. ir O Grave No. -�--
•
(Signed) ,.- � ,. �ti-�--�,. C-e-7
(Person in.charge)
Address G' ` e =• `— //
'
Zyyam y�,
Person in charge oust 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 or NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FUR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.