LaValley, Mary • m VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 D LE BLACK INK. _Timm— Registered No-
-Aftft-4,e
Dist No.i.gl.County... .. .... .. ... . r Cityir
.d Lit j v ctigailf city, give street a resit)
4
Name of deceasec*-1-2/1aergr Veteran
(If veteran, give name of War) ......e
S '4111111 4.11111 C011tk& •ei ced (wri ,wl-theww-Ord) "44144 Date of Death. 711aey.
Age. ..ir/ Years 7 .... .Days Birthplace.i.cies -
Cause of Death
Certificate was signed by M.D.
Address '141e2 ---.. —4P.,....?
Place of Burial (or Removal)....kagia-40-44.-4.4.c...4.-.. Sctal.....vea.,,,e' --ifieGreecic—(4a,44. i,r
(If body is to be temporarily held,till in space later) 1
Cemetery --________—.--- ---_
Date of Burial 7,eLett ./Z 19
(If body is to be temporarily held,fill in space later)
Thg 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 thesame for registratio have recorded it in my Local Record with the above stated Registered
Nuicbj, and on basis t f I BY G NT A PERMITza_d e --Az
to .. r.
___Osune) drees)
the -____ _ __
to hold ternpora ' n he body.
Undertaker or person hiving Datet , charge/r) Inter ove,o laao:12Zeer.42......]
. 00",..3 19.1 (Si ..7
Local It
This Perms is sufficient 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.
1
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-
Date of <,_ t - ( was ` i9 ;
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.) J
Section Lot No. Grave No.
i d f)d_aL(S gne )
(Person in charge)
Address �� ! ( C /t_
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.