Achenback, William Perm V .al NEW YORK STATE DI.2ARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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 e end No._..../ !._._
.�/
Dist. No ��� �Couaty........ � �� C, Village
or City ...76
(If city,give street address)
Name of deceased # ��GZ-� / � G.- Veteran -7't--e---
//�J/ Single, married, widowed, (11 sterna. give name of Was)
Sex Color...f�/ or divorced (write the word) / �' Date of IT ` r 9 S�
Age e Years. } =.Mo ths ays - Birthplace /- ` : 7; '
. � 'c-cam
Cause of Death
Certificate was signed by - . M.D.
Address .., C
Place of Burial Removal) >2 .,:z s a. . } 7
(If body is to be po ly held, in specs later)
Cemetery k..G..� ,'' Date of urine /
19... E
(If body to to be temporarily held,fill in space later;
The Certificate of Death containing the above stated particulars, having been presented to me, a ter 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,ito � on the basis the f HEREBY GRANT A PERMIT,
-1) /1 —
f, (Address)
the fr7- a7� ..: . -V to hold temporari. and... the body.
(Undertaker or pe n having charge o 6 )
�In''eer, remov ,or � e se [stain howl)
Dated (Signed) Local Registrar
��
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mats (wbjest to local
cemetery or other regulations),unless removal is 5y common carrier, in which case a Transit Permit (VS No. 62) is required.
62e,-67
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date q • ' wad _19,
torment;:y/
( m✓of Cemetery, Crematorium, etc.)
Section A 7Lot No.771- Grave No. /
(Sued /1Gz'� � eery9e--(V.
(Person in barge)
Address
Person in charge oust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE- _
WENT, write across the face of the Permit the wards
"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.