Bennett, Leah Form TEL si_ NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 an. •tance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
330i ONONDAGA • :,,T SYRACUSE
Dist. No County or City
i (If city, give street address)
Name of deceased ' -' a. „/t aL.Z Veteran 7444
( Single, married, widowed, J 1 (If veteran,-`ive name of War)
S . . ..Color..(2, .or divorced (wnte the word) ((,)--ee c'e- Date of eath 1..�G�t I / 19 " -
Ag Z, Years , . Months Days Birthplace -e.:a�. . ..t. .�:..i�.,
Cause of Death....... .c1,a .4“- d - ...r �.. ►..r..a...
Certificate was signed by' ..,...7- ,��. . . . . M.D.
Address 81. H.a i,A:�r����, ~. .
Place of Burial (or Removal) - ,,, t,u ,.... .... ,p...�.... • (-ii...i.....
(If body Is to be temporarily hJd.On in space later)
Cemetery ,.c•.::..i...4.s,,,-; Date of Burial l<t.i 19
(If body Is to be emporarily held,All 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 thereof I HEREBY GRANT A PERMIT
to ,21 U, CC -'li;c.:A 4..G7-L....W.:. 4-2li �;�:..X dui- ::.r..12,.(
—� (Name) p (Address)
the '.Z 4.Lt. .. to hold temporarily and .4 s.a r the body.
(Undertaker or person having charge of a rpae) n er,Aewove or otherwise,dtaoose of to bow])
Dated T14:11/1. / 19..57 (Signed) C/Uefo-e-te.. a/t !,42 �„�
ti E U P TY Local Registrar ;i44
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of t e {.object to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH IN DI',i1D TS OR CREMATIONS
ARE MADE
Date of, 4225.d was .7 _5 lg
(Interment or Cremat on)
Js'-2/ •
(Name of Cemetery, Crematorium, etc.)
Section " Lot No. /9/ Grave No. I
(signed) ��2'G'
(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 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.