Lamoruex, Charlotte Form vs.ii. NEW YORK STATE DI PARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit can be signed oily by the Local Registrar (Deputy or subreglstrar) 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 9,e )_
Dist. No.�L°► County..._. fl a'"'''� or City �!'u4+r
Qi��.lt (If city.give arrest address)
Name of deceased Veteran `----
/ Single, married, widowed, (If veteran. give name of Wee)
Sex - Color W or divorced (write the word) If4 "•""`t/ Date of Death Z 7 19 S
Age y:.1, Years GG , Months Days Birthplace 3*i.#- . ... . , `�
Cause of Death JC,"i ::!ft 1
Certificate was signed by t7, - .. M.D.
Address uyl.... .T 0.14 7
Place of Burial (or Removal)
(If body Is to be tempararily held,fill 1a ace la t
Cemetery 1 .P-t""� t -Date of Burial � 1d P 19 Y R
(If body Is to be temporarily beld,f 11 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 Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to , .�.....A - .. , ti
(xatne) (Address)
the "��"` "`'� to hold tempos ':y_and the body.
(Undertaker or person haying charge of corpse) (In er, ore, r th a se dianose of(state bow))
Dated z/ f° 19...E (Signed) ' emu Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Mate (wbjeet 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 of '6'‘ was Fla . td 19 SY
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc
Section Lot No. Grave No.
(Signed) /1(242 'D7CA n
(Person in charge)
Address
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 fiords
"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.