Suirslay, Reubin Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr 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.,Lt 8._....._-
o-C 0/ Village
Dist. No County.. .7fr - or City , -df (/`c-'
• (If city,give street address)
Name of deceased -e��'d -;'L- �, "- Veteran `ate
y' Single, married, widowed, 0 (If veteran. give name of War)
Sex i Color 7/ or divorced (write the word ,f',Y.. ...a Date of De :..., 19.,.{j'
Age .;?,,....Years Months .....Days - Birthplace ���
Cause of Death (.... :r 4 ,,n,- e.As,/
Certificate was signed by ,, ,. ..,;,, ei,;,rr- ,A`-0. Alt— M.D.
✓.Address. "i �e- - 0 •2`:..,
Place of Burial or Removal) 1 ..� �... ..,......?1.:.
(If body is to be te orarily held, in a ace later)
Cemetery... .. ... t l., - Date of Burial >a / 19.s/.
(If body is to be temporarily held,fill space later) /
Tho 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, i d r the basis thereof I,HERBY GRANT A PERMIT ..
to ..G...�.64t-vt-i-- .14', •.4..t t.':x..: ^-x n/a--6, ✓� .
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the me. - to hold tempo ly and.. ...�rsrr' ^/ the body.
(Undertaker orperso having charge of corpse) - �(Inter,�emov oar otherwise snose of[state how])
Dated k ,1...//.........19.,.' 'te (Signed '— )...-k�-a..�. ec-Gz i Av'"t . -0,,e....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any past 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.
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'ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of i01*`ti was N1 10 19
(Interment or Cremation)
(Name of Ce etery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 1' �-tom'"" Ad " L
� , 4/ , '
Address ''t. ;
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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 i slocated. _ _._.
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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.