St. John, Joseph Form vs.OIL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr This Permit voss 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 CERTIFICATLQF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town - Registered NO.. ,.. ..
Village '
Dist. No 6 6../.County (- or City (If city,/ 24
street address)
Name of deceased ,..e..11 Veteran
// n le, married wido (If vet n, tiv name of War)
Sex. / r,Color or divorced (write a word) ` ate of Death.......... ... a�L 5 19._ .. I `.
Age Years . Months Day Birthplace.:
Cause of Death — .r .... .... : .... .
Certificate was signed b M.D.
Address :,..r,,- ....... .. ... `- y
Place of Burial (or Removal) `.�
(IL body Se to be rarity d,fl a 'later)
Cemetery l t-e` 4- - Date of urial , 7 19
(If body I.to be temporarily held, Al in apace 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 bas' thereof HgREB NT A PERMIT - '` l
c -f
the " :v._, -- _ 2 .,..to hold temp rily d the body.
r the se disooee of[state how )
(IIsye�ertaker or person havingcharge of (In t// I
Dated * 19...:a.tz_ ___
(Signed) .. '.--e'ir '
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part a the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSIMEvT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ofy 1-11.iL , f was t l 19 J\
(Interment or Cremation
(Name of Cem ery, Crematorium, etc.) /
Section Lot No. Grave No.
C‘a
(Signed) /l.J j /t/`''�--'
(Person in charge)
Address D ' Jati X 6
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frean 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.