Bartlett, George r
Form V&aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be maned only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tows,
Village, or City) in which the death occurred after the FILING aed acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No. _ -:_
Village �
Dist. No 5 6 Cs" ..County.. ...� '2 or City x -All-
(If
_ (If eltl',give street address —
Name of deceased — /� "F�.� ✓�� d�z��'
Veteran
___ ` / gle, married, widowed, (lI ♦etersn. sire came of w.�>
Sex /%,... ...•.Color.•.• `or divorced (wnte the word) 7ia- Date of D /.. ...�./................19..a�..-.C"
Age . Y s Months _.. ays Birthplace b-r' 1_, ,7Cause of Death 4�L .. TT
Certificate was signed by .. _ M.D.
Address (o �c�roc... . �� r/ ' l
Place of Burl (or moval)... ...
(If body is toempor ly held,All ace later
Cemetery.. �'.. .�:c.-r—r— Date Burial art,-
1 19 ,s-
(If body is to be temporarily held,El in space later;
The;Certificate of Death containing the abov stated particulars, having been presente to me, after careful exami-
nation, the same appearing to be COMPLE E, CORRECT, AND SATISFACTORY'AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the also? R istered
Number, and on the'basi ith HEREBY GRANT A PERMIT af______C
to i�:j<Z"V ( ����%gin
(Na refs)
m
the �Q. s_.., ro hold temporari.y and �. the b y
Unde ker or�ding charge ) ,(Inter. re nowt dispose of[state how))
Dated .11/.1/I/ 19 (Signed). Loc. .. —cis tru
This Pe 't is sufficient for the Removal (and Interment or Crema ' ) of a body to any part of the State (eableat t• local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is requires".
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTUITS OR CREMATIONS
ARE MADE
Date ways i 19
(Interment or )
(Name of Cemetery, Crematorium, etc.)
Section Lot No.j)---o ; Grave No`3
(Signed)
(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"iri- charge," and-FILE-PEWIT-WITHIN THREE
(3) DAIS 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.