Lynch, Eugene Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subresistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING anti acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No
Village ' • ~
Dist. No - ' County........... ./�sF»-,re or City / r ; � 4 L�.
(If city, give street address) /
Name of deceased .24 .. ,, -4.- Veteran `h
/,,' Single, married, widowed, (If veteran, give name of war)
Sex Color...A or divorced (wnte the word)..> -/ Date of De .th.......7�.,...Z... 9.. ..
Age . Years . M nths ........Days � � / ,Birthplace...../.ti . • 4.- .... A elh ,�..
Cause of Death 6LeK ....... ...... P-/-(4--1.: 7: a
Certificate was signed by .. ... 1.T..., `fib..‹ ...... M.D.
Address J c O,, .�.
Place of Burial (or Removal) /-:(ko, 7 rGr.I'..4det. rr- i )i• "`
(If body is to be temporaril held,All heldll In a 'later) (/
Cemetery ti L i tc„il C�ip-t_ Date of Burial ?� y....19
(If body Is to be temporarily held, S n space later)
The Certificate of Death containing the above stated particulars, having been presented to me, a ter 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 the basis ther of-I/'HEREBY GRANT A PERMIT
/, (Na �— (Addrels) j
the / � ,, �,, to hold tempo. .y a -�r,G - the body.
(Under er or son having charge of corpse) (Inter,re o moss of [scats howl)
Dated J, . `f 19....5-, (Signed) ... .... ..
Local Registrar
This ermit is sufficient for the Removal (and Interment or Cremation f a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in whic case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXiUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of k-4_, �,Jwas / 19 ✓- )1.
(Interment or Cremation)
4/,
(Name of tery, Crematorium,, etc.)
Section Lot No. Grave No.
'l n
A
12/?)
(Signed) e #t• Pi(°
(person in charge)
7 /
Address '' ///
Person in charge oust return this Permit to
the Registrar of his District within SEVEN (1) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
RENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THhEE
DAYS with the Registrar of District in which
cemetery is located.
t
SE)CI'ONS, 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.