Rogers, William Form ys.et NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rtir This Permit can be signed ealy 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 BLACK INK Town Registered No._...:_.1`�.._......_
Village A
'Dist. No County.... C C%.c_ or Cl 4.� V ' C -
.. g� (If city, give street address)
Name of deceased .». ...�'Yt....... ..... . . . ...: - Veteran V —" - /2/3 -/9 y
�, �� Single, married, widowed, O veteran. give name of War)
Sex y� Color !'x� or divorced (wnte the word)...' " '7-1- Y Date of D fj �yl.. .. 19
Age .,1....Ye s , Months........'.../..�.....mays Birthplace .11 �t —CA. j :1•••
Cause of Death 4-r A-err.. �`c.�s,z- k ,,-- . .......�0.:.;.zn( .-e . z4 ,
Certificate was signed by . sr.--». M.D.
Address 4e).41.
,. 'L •
ly,
Place of Burial (or Removal) ,.11.7.0.3..). „., r - // .
(If body 1s to be tempo, be epee*later) � /
Cemetery -)`/ . .!.Y ..,....a...Q:,:.,. ./ Tate of Burial P-/ / 19
(If body 1s to be temporarily be1d,, 11 in space later)
Thq 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, on, e_basis thereof I HERE GRANT A PERMIT ��
to , .��n/��G..2.:Zc. y )?'t ss:z:i a G1C:Y, �.:,..L. •x ,...4.
/ (Nate_ __ (Address)
the eZ'a� ..a..C.r:. t..i to hold tempo ri' -and 1 .. the body.
(Undertaker or a having charge of corpse) (10er, .pgot �c se dlsoose of (state how])
Dated a..p ../.y..........19 • (Signed / �� z-7 -6=
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. fir: '- required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEM NTS OR CREMATIONS
ARE MADE
Date of L �} d was t L�s'L(,t
(I to nt or Cremation)
• (Name of Cemetery, Crematorium, eto.)(
Section Lot No. Grave No.
(Signed) e t%t?‘
(parson in ckarp)
'fr4Address F.
mot/ r
Person in charge mass, return this Permit to ,
the Registrar of his District within SEVEN (7) DAYS
from above date. I o per" sdn is in charge, the
FUNERAL DIRECTOR or UNDERTAKES MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," aid 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.