Shepard, Roseanna Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ur This Permit cans 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 CERTIFICAIEy OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK -Town Registered No. - f f
Dist No - -J County ) - 1-- or City �--'���c-�-:"—se_.
C.
r
(If city, gic treet address)
Name of deceased Veteran
Single, married, widowed,
(If veteran, give name of War
Sex....1. .. .. Color h� or divorced (write the word . Date of Death /....3 19.:. '-
Cause( Years... .,....M nths.. .fr Days •rthplace
Cause of Death .s ue, `-c 2 .�4.. C.--
Certificate was signed by.... .... ........ . , . M.D.
Address
Place of Burial (or Removal .� -
(If body is to be trprarily,�dl up later)
Cemetery c-ef iCCC Date o urial /I 19 `'
(If body is to be temporarily held,ii in space later)
Thn Certificate of Death c ntaining the above stated particulars, having been presented to , fter 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 stat Registered
Num nd/ the basis thereof I HEREBY/GRANT A PERMIT �j
6, (4` revs)
the -�1'‘-�x"---v ` -e . to hold temporarily and the b y.
(Undeiter or person having_charge ofgor ) n (Inter,re oveeoyth .e disooae of [state bow])
Dated f :?�— '- /.1_?..19....a.. - (Signed)... �`� Y�=��- 1 .,- ,-::: ,*__'----
Local Registrar
This Permit is su cient for the Removal (and Interment or Cremation) of a body to any part of 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.
FNDORSEMFI.IT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH IN DI',1I0 TS OR CREMATIONS
ARE MADE
Date of was 19
(Interment or Cremation)
'
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) � �
(Person icharge)
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 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.