Provost, Mark Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
silr 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 WRITTEN IN DURABLE BLACK INK. T-ewn Registered No._ ._...._....._._
Village
Dist No / / Co on or City
nn (If city, the street address)
d-r
Name of deceased ,l f.... Veteran _
�,, / Single, married, widowed, (! veteran, liven a of Wu)
Sex... ... ........Color `"' or divorced (write the word) . . ...Date of .. oX
Age Year Months D s B. ce....
Cause of Death '
Certificate was signed by • '
D.
Address.
-?7e---v-44-
Place of Burial (or Removal)
(If body Is to be temporarily held,fill in space lat V
Cemetery ate o urial ) /l 19.. ....
(If body is to be temporarily held,flll in spat ater)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful a ami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATI- .ACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Lo ord with above stated Registered
Nu , n the basis thereof I HEREB GRA T A PERMIT d
to !+'
(Name) ... in)
the to hold tempo ri and .... ..... .. ... e body.
(IInd k pe a having charge rpae) r remove, r di 5 '/, , , )/
Dated 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to Deal
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 PH )N 1N CHARGE OF
PRFAISES ON WHICH INTERMENTS OR CREMATIONS"
ARE MADE
Date of y,.�^' 'r was - zJ .. // 19kry
(Interment or Cremation)
-L,,,,....,..,,,,_„ ar,_„_,.4-,---7
(Name Cemetery. Crematoriums etc.)
Section 1 " ``' til-Nit Apade No.
i
(S fined) Peel 0
(Person in charge)
Address • 6. 6 6 6
or-e-La 5t - r
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.