Van Antwerp, Caroline Form vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 WRtITEN IN DURABLE BLACK INK. Town R ' tered No._._....:.'-)..1.__._ _
Village -'
Dist. No..S.L:i .County......142.t�..i ,."r_% - or City 1, Q- 'k'u -- t%t.(i
_. (If city,give street address)
J � f
Name of deceased Lea, ..4: : ,,e-A:‘ k �i.,--1 �f''«^^`t' Veteran 1 z�
Single, married, widowed, ( f reteran, give name of War)
Sex p1�1" 4--,2-EolorkQ :Le or divorced (write the word) 161i ("7"-- Date of Death. Lt .tr - 7 19.
Age 7 ,J rears � �.Months. ..Days Birthplace....; --- - ,-" - i. I's •,y,
Cause of Deathtkie..4&:s�v' _ -e-^14 v ' .A n cuc' z cP-( 1 + i-*=4
Certificate was signed by 4) i7 • .E" 74 i!i.4.h- „a.t .,., M.D.
Address....,,...0 C/ 2::4,. is,...:,,:,k.. 'z-,4.. ..... `k...1'
tis
Place of Burial (or Removal) t, .- "1 -z" -
(If body 1s to be temporarily held,rill Dace later) �j T7 r"—
Cemetery J.R:L�,_'-► �.1 u-t-'+�-•Q...0 t '. Date of Burial (' 19 7
(If body Is to be temporarily held,fill In space later)
Thu Certificate of Death containing the above statd particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and, on the basis th ,I H�E�tEBY NT 4 PERMIT , i
to .\ 4 ieVf,“4.4- I1+�I N"w,.0' ' .a.-.,,i:Ft.r. 14zie .4 �rJ- -..ht:1 .�-)a-g/!..1.. ..) i i
� �jz'j (Name) 7(Address) the body.
to hold tempor rily and ... z�
( dertaker or person haying charge of corpse) (Inter,remove,of otherwise dis*�ose of[state Low])
Dated.... pi:. �% 19. . (Signed) : .!:-1�` ..7;1.. )...lE ,%k..k. L:4/4
Ldl , q Local Registrar
'' Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (onbject to local
.nliacemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
C.c`-,2._
-7 e-4
--
INDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-
Date of .7,77- 't om was: t� Lir19 e
7
(Interment of Cr lion)
. ,.."...112-1 / „
(game of tery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) /2 ,/E4,.- c,.LG Gam'': -' '
• rood in charge)
7,
Address � 4--" t-/!7(2-e-� �,ey ''ti``"''' 112--�
/Person in charge must return this Perm. bto '`
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," mad 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.