Robitland, William Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itr This Penult 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 BLACK INK. Town 4444 Registered Village
—
Village ..114.
Dist No‘.4.4.1.1......County.......V444411— or City
Wit ,
Name of deceased .. 414/144e (If city, give street address)
Veteran .
.."
(If veteran, give name of Ww)
Sex 41 ,,,Color ii/r Single, married, widowed,
or divorced (wn
tethe word) Date of With. .W.2--P 19 Fr
Age 7 r Years Months
Cause of Death .6..e.etkeut...t. .1/74.444A-444-
Certificate was signed by haw- 4 A
M.D.
Address / f i."....{ ffe"r‘r'' 1-444 ,)--461-4
Place of Burial (or Removal) kt(If body body is to be temporarily held,fill in spice later) 5-y
Cemetery Tde?...ehttl.. Date of Burial
(If body is to be temporarily held,Ill 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 R cord with the above stated Registered
Number, on the
to asis t f lerREBY GRANT A PERMIT
•2 .
q
the (4.A4.44444zName)„
to hold tempor )t,and Aer,444td (Address)
i., the body.
(Undker or person having charge of corpse)s re_59e, le-,4oe disnose of(state how])
Dated 1. 3 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem ' n) 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o f} e-, was � p Z 19 J d
(Interment or Cremation
•
s)( , r
(Name of Ce tery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed). , 1��/�� ,
(Person in c5arge)
Address )-4° > •
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.