Smith, Edward Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit tan 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 CERTIF_IFAAE QF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. T-even--
Dist NO6. ....%Y..County (Z)C''',"---'."— Villagc
or City
(If cttalve street address)
Name of deceased.t—drA-4 .--11 Veteran
(If ve a...;: e name of Wag) ....-
6c) Single, married, widowed, '
Sex (.44, Color or divorced (write the word) .Date of De th. ....,„/‘7 I9g
Age / Year Months.. , .Day • Oace
Cause of heath -
Certificate was siwied M.D.
Address.
Place of Burial (or Removal)
"---1- 7,
-,
(If body is to be te frorarily held,till in spac later)
Cemetery Date o Burial. C12—<,---- / / 19..o-e'.
(If body is to be p arily held,fillin space later)
Tho Certifica e of Death containing the abo 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
Npler, and on the,s.br thereof I HEREBY GRANT A PERMIT
(A to hold tempo Is) ....isi.
the 'ly and
ky or per3Rti having charge tcf..c9pae) l _(Inter,r ove, spsf"-- ose of[state b
Dated.2;r1 / 7 19.... . (Signed
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any pelt of the State (pubject 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 SENTON OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
C _
Date of :° �r - was ( ,• r/f/ 19 (..
(Interment or Cremation) .
(Name of Cemetery, Crematorium, etc.) "
Section Lot No. _ Grave No.
i •
f
(Signed) •_. 11�, ...- Cd .� _ . .
(Person in ►arge)
Address L' L 2C7 �,�7
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.