Johnson, Benjamin Y-nrm vs.it NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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, LECUBLY WRITTEN IN D LE BLACK INK. To3.1An- egiste71-11.9,-___...._..........
Dist. NcHt.53-4 -
Coun -..egetta Village
o pe.'<i-t9/ ' • -&./ '
Name of deceased (If city, give street address)
teran
(If an,veter give 7me of War) „4-3
Sex....c.g.Color A.
Sing married, widowed,or d orced (write the word Date of
a.erot<" 1 Age Years.. onths nays
/* Birthplace. .
Cause of Death , ' ) , ..,
Certificate was signZ. di i - Alio' ' -* M.D.
P.OV
Address _,
* 4110"0/ .
Place of Burial (or Rpmoval)..../ --fi.: .
(If body is to be temrld, y.-1,,tg ./1. ,' later)
Cemetery i ( IV ' ..• /. 4eorQ Date of Burial. gY 7 19 bi 7
. . .
(If body Is to briecnporirily held,IR/ . space later)
The Certificate of Death co aining the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same registr tion, have recorded it in my Local ecord ith e above stated Registered
Num- and on b ' e tiEREB GRANT A PERMIT ,
to - .g. • c4C16t7
... (Name) (Address)..2".
ell
the te.'"----- to hold temp 'ly nd .4,------ ' e body.
(tIndertalT7irsonrIng charge 9fifyi) nte , re ove,or otheor snose of(s bo, /
Dated j / 19. ,,s (Signed) , • , ••••
i Local R
This Permit is sufficient for the Removal (and Interment or remation) o a to any part of the State (aubject o local
cemetery or other regulations),unless removal is by common carrier, in which cas a ransit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of ' . / 9 r was 19
✓✓ (Int6 men t er.ere ar)
(Name t Cemetery, Crematorium, etc.)
Section -- Lot No. 14o Grave Nbd"-ii
rC/V „ �
(Signed)
(Person in charge) •
Address ' ` "s-°
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.