DeMarsh, Harold Form VS.St NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ur 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 and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE SLACK INK. Town Registered No.___-. ±_
Village z ���
Dist. No'-' • ',. Coup .. .2 e-z� or City ��� ,
ty. ...
(If city,give street address)
Name of deceased �..r-.G ...... ��.... �., Veteran !� 4 �
(If reran, give name o'f War)
7 , Single, married, widowed, /
Sex y Color..& or divorced (write the word)...&'V /f?G.:Zc( Date of D9th. „/. .Y.. ..19.:
Age 6...� Years. Months Rays , Birthplace :.- �7 .... 'Y -e��•.4:••
Cause of Death .. —7. 2 r `�.....lz..c.s ...
Certificate was signed by �,,,;, ..,.s... .. M.D.
Address � 1�: .iC �y
Place of Burial (or Removal) � -/.:�
(If body is to be mporarllz_heldA)in space 1
Cemetery , :!%,<`. 'iC. --.;.w * 2-e-k,, Date of Burial .:-/ / 19..E
(If body la to be temporarily held,fill 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,ond on the basis thereof I HEREBY GI WIT A PERMIT /,' i �/�/
to ...cr,. ..C:4.-z:i.� 't '",titit`r .. [.'flay Y* 4.:G �L`L V'_� L,/ /
Nang} (Address)
the •
y2 `r -Ce p to hold temp rarity nd..�... . the body.
g
(IIndertak r r person having charge of corpse) ( , 7 (Inter,remove.qr otherwise dlsnoae of[state how])
Dated 19- -- - (Signed) - ��((�� , ,/,-' / - ./
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'tab (seibject to local
sr-niary or other regulations), unless removal is by common cur.-Err, in which case a Transit Permit (VS No, 62) io required.
`
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of a �2� - 19
�
n /
nt or Bw�Lia(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 7 , AJ ld1 G%
(person in ekarso)
n
7
Address 01 v --+&2�/ '
r
Person in charge rust 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 UNDERTAKES MUST SIGN AMIE STATE,
SENT, 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.