Bennett, David Form TEL Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Penult can be signed only by the Local Registrar (Deputy or subregis ) of the Primary Registration District (Town,
Village, or City) in which the death after the FILING and acceptance of g CORRECTAND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. Town Registered No—
Village
Dist. Noi.i.i4.... .Z ---'€---V----t
r "'•A / • eir-etr-
If city, give stree .....X.
Na of deceasedc_ _C -4-A-11'k. . Veteran
, Single, marned, widowed,
Sei.11..v"---- lornit: ; or divorced (wn e the word) te of Death(16"' • e me ° WK_____.at 7 5(
Age Years Cet .M ths .......Days
7
r* lace
Y P
Cause of De th .:* "Ael..:4 .1
Certificate was signed by M.D.
,... lirg
Address .2.,/
Place of Buria (orir oval) ...0 1
(If body is to be .mpo r held in s a f ter)
Cemetery -.,--C- Date of B rial /7 1„97, ---
(If body is to be temporarily held,fill in a ace later)
Tha Certificate of Death containing the above stated particulars, having be 'presented to me, aft careful exami-
nation, the pame appe ring to be CO LETE, CORRE T, AND SATI .ACTORY AS RE RED BY LW,
I have ac ted th e for rigistratio ye record it in my Local ecor, with th a e sta egis
Number, s• f Vii ERMIT • 1 ...
the... / tem•I ran A it 141-titeld ' Iti",
-.An ' fie
the bog'
(Lind kffprtving charg7r) se nose of[s te howl)
Dated 19. (Signed) ‘
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre‘. on) of a body to any part 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was 19
(Interment or
I. K„-e-ems
(Name of.Cemetery' ) ..
Section Grave No. -
1-1
Sideyy�-'' 'lC .L
/ (person in charge)
Address
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frau above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER BUST 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'Regist.rars are re-
quired, under penalty, to reportviolations thereof.