Berber, Violet Form VS.QL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lir This Permit can be aignod only by the Local Registrar (Deputy or subregiatrar) 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._ ._...._........_........_
Village
Dist. No" 66 l County or City - -(‘
(If city, give street address)
Name of deceased Veteran
Single, married, widowed, Ofveteran give name of sear)
Sex . Color or divorced (wnte the word) ,"''"'`' Date of Death 1l 19...,....
Age Years Months Days Birthplace '� ,> ' ," .�i
Cause of Death_.: w"- , `..x'`" `-- ((
i.
Certificate was signed jy e " - M.D.
Address ',./,".
Place of Burial (or Removal)
(If body is to be temporarily held, 411 in space later) / r -
Cemetery -< Date of Burial .f 19
(If body is to be temporarily held, fl11 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
Nu;er, and on thesis thereof I HEREBY GRANT A PERMIT / ,/ 7rr k AtO.YT_ T t♦ _ .d� a 'i
L1 (Name) d I i � ( ,) the�
the.......,...'Z to hold tempo rily body.
(Undertaker or person having charge of corpse) (Inter, ove, r theme nose of(state howl)
Dated.. ,f 19 ' (Signed .-.-r..... .`:s " . ... ��`/ - .-N.-(-- ..,
Registrar
This Permit-is sufficient for the Removal (and Interment or Cremation) of a body to any part of Use Nitta (mbject to local
can..ctery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
o a -.
ENDORSFMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CITATIONS
ARE MADE
Date was , f s j 19
(Interment or on)
. il- -j •
(Name of Cemetery, Crematorium, etc.) 1
L/f1G,761,44.3---1(9.
Section Lot No.. , , Grave No.
(Signed) . •. (112 { ',
(Person in charge)
�LJAddress b �,�,f Ø2 - 4
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 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.