Daniels, Milo Form VS.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fr 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 CERTIFI AX�
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK — Registered No.�
Village ___1��Z /� yT'�A / ,s
Dist. Nol�.6t..C1.�County......--�.. -r.^:t-,c-- \i
or City �-e- -try j
/1 etts, ve street address)
•
Name of deceased `,',�‹c{l/ Veteran
(If veteran, give name of War) ...
Single, married, widowed,
416
Sex olor or divorced (write the word) ate of each - _ .'
Age 4° Y rs Months Days 0.47_Birthplace `"'.�c.�.I... ...... .....t&4_
Cause of Death I. a
Certificate was signed ... M.D.
Address ... . .... .
Place of Burial ( Removal). .. „�.11-- ,
(If body Is to mporarlly hel fill in apace later)
Cemetery.. E ,E -� --� `i Date of Burial ' . 19..5..
(If body Is to be to orarily held,All In space later)
Tha 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 s Registered
Nu. . - , and on theobes thereof I HEREBY GRANT A PERMIT
to.., -
( ame ress) `
the to hold tempotraril _and the y
. .... ... . ... .
(Undertaker or pan having charge otcorpae) <." -Inter,remove, r o erwieeEi400se of[state how])
Dated � l 19..b...� (Signed) _:�-. ;::�,,�:...:L..�.:. '--� .tM:r ..:f,:�..za ..T::•....�-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the 'late (subject 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
A
Date of -� (as L 19 ` / `
(Iuteraent or enation)
.
(Nave of Cemetery, Cremtoriva, etc.)
Section Lot No. Grave No.
(Signed
(person Sn" arge)
Address Y'
Person in charge must return this Pelmif -"-
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 cords
"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 violation' thereof.