Lucia, Grace Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ttsr This Permit 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 Registered No._.._...._............
• Village
<;
Dist. No' Countyn... ... 1....(.a5...{: ..... or City -...--eeee t" . c_e
e �N (If city,give street adds)
Name of deceased t N.1 44--er.re- a::4:C::G. �, Veteran
Single, married, widowed, (If veteran. give game of War)
'
Sex -C.:r!`:.::.Coloru.a4-U,....or divorced (write the word).../.{�l f ti42 Date of Death 1416 �2 19.`,.{-�..�
Age 7 ' Years Mon.ths /, Days _..-- Birthplace `'2�& ' ..,
Cause of Death — '� .. - r k�� y -mac-ec- , A`.��: t ,czr xYl.. .a
Certificate was signed - /I ' T` � rL- y M.D.
Address ,. ...4 �G.kL. '�2. .4
Place of Burial (or Removal) .. t �7 «` ‘4-..4--4-4
(If body Is to be,tewpor Illy held,fillip space 1 ter)
Cemetery ,.! "t..vti l'lhi,.� 6- — �, Date of Burial.���� 4/ rrr 19. ...�
(If body is to be temporarily held, fill in apace later) r
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 �,the�blts_ip hereof I EREB fERMIt�,7 G� , ��
t0 :l.,iL4 L�!L' :1� YY K'�'r'� �r '.74•r.. •,.:. ? G( �.� '` c-•k;y� t
f`11sins) ,�ddres�
the .i.a..`,.. ' to hold t poraii'ly and / !�4.14.," the body.
(Undertaker of person having charge of.corpse) (Inter,remove,or of se disnoae of]scats howl)
Dated 19 '.. (Signed) , ...1 �f ,,,4.4?�Z G,/
Local Ttegiatrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a ldy to any part of the State (.abject to local
cemetery or other regulations), unless removal is by common csrrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX1ON OR PERSON IN CHARGE OF
PREMISES ON WHICH IN'iEMMENTS OR CREMATIONS
ARE MADE
Date of was IIIt 1 D 19 5-
(In ferment a,.. {p)
(ICL4,tit •fr-
(Meae of Cemetery, Cre orium, etc.)
Section Lot No. Grave No.
oe4
(Signed) V lJ) • PotA "
(person in chsrge)
41:44a11---
Address ,/f,/r./
/11,?//1(r'
Person in charge trust 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.