Buckbee, Harry Form vs.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can ba 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...........ce...7._
Dist NoLlt.Q.4....County '''') `"--'---,'--4--,--__ orilhge City
(If city, give street adaress)
Name of deceased. ,il,--1--/- 4 e.....)4/ ----rl-r.,,, -/‘- ''.---,-.--"-- -1-4---t--- Veteran
I ----"' e'i•fiarried, widowed, • ,y, f If veteran. give narne of War)
Sex CP
.,-... olor 4".4-1 o --
r ivorced (wnte the word)"- --y, -----0---.Date of
7 Age -.. Years Months .. ..... .Days Birthplace
Cause of Death ,,,,
Certificate was signed by - :ay.': eedi"-7- M.D.
Place of Burial (or Removal) T,i"- --- .,./1-------- --,-,-----.r.,,,,.. . 7-----1 '`7 6r-,---'-a-ffs.v..--tew.-.
(If body is to toe temporarag held,f11 In space later 1 —Cemetery 1"W /,r(---4--r. --v- An-rafv.-.4..,:e..-., Date of Burial s:51 •--- 7
(If body Is to be temporarily held,fill 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 Rune for registration, have recorded it in my Local Record with the above stated Registered
Number and op the basis thereof I HEREQY T A PERMIT -;-' , /
-- - d z
-47 - ---L0.-
to *-1---t-c.---C.,- ----,--.
, ... . ___,........ ;Idrese) -,
to hold temporarily and „„..- the body.
1.:,
(Und,e_ ker or paw corpse) (Inter,re
n having charge feniove,opinyierwiwdispose of(state how))
---, ,
Dated (.4, 19„.... --'
Y g ,
(Signed),..„;-- - --/-4-19,./ ...------
1 Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation),..cif a body to any part of the State (mtbject 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 CREiNATIONS
ARE MADE
Date o : Z was .z 19\
(Interment or Cremation
'9".!--;i7(;) r
(Name of Cemetery, Crematorium, etc.)
Section Lot No. _. Grave No.
(Signed)
(Person in charge)
Addresske---
f27,/,,,„-t-,&._„'
Person in charge crust return this Permit to
the Registrar of his District within SEVEN (?) 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 violations thereof.