Barber, Horace Form vs.at NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed ealy by the Local Registrar (Deputy or subregistrar) of be 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._._.=::._......_._
i > Village
Dist. No County......». ..,4:...«?: 'c or City ..
(If city, give street address)
Name of deceased '" c--' ' Veteran
(If veteran, live name of War)
Single, married, widowed,
Sex Color /r or divorced (write the word) Date of Death 19
Age Years Months Days Birthplace
Cause of Death
Certificate was signed by ,.— M.D.
Address
Place of Burial (or Removal) —
(If body 1s to be temporarily held,rill in space later)
Cemetery Date of Burial s:.. 7/ 19
(If body is to be temporarily held,1111 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 !/i,,
(Name) (Address)
the to hold tempo ly nd the body.
(Undertaker or person having charge of corpse) • (Inter m ' disnose of[state bow])
Dated 19 (Signed) meal Registrar
This Permit is sufficient for the Removal (and Interment or Creme of a body to any pert of the State (enbjeet to local
se.'etery 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 INTERMENTS OR CREMATIONS
ARE MADE
r / _
Date of/�'� C+2�-��..f 7,c / / 19 4
(Interment . _ n)
(Emile of Cemetery, Crematorium, etc.)
Section / / Lot No(3/Z 7 Grave No. /
(Signed).��CL
( rson in charge)
Address ( 112 , '
Person in charge must return this Pero t 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.