Cutter, Baby Boy Form V&Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit tan 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 CERTIFICAIE-OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Mw11 ' Registered No—. /..-,. .
Village Se, y
Dist. No'5-6°/ County.. , 4.`-- ,. Or City _- - z
(If . y, glee street address)
Name of deceased ._ feles. , Veteran
ngle, roar eod, widowed, I OF veteran, give name of War)
Sex /72/akolor 64/ or divorcedllwrite the word) Date of pea le •191
Cause of Death
Age Years M.9 . •a,ys / Birthplace c' -:))- et— - 21
-
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Certificate was,_!igi (.1 1 by. --/--)- O' 7 "Wlyitsri ., ,---v-, M.D.
Address er"...., /**/• . i
/...' • ,Lcle >i,,i,,_„_.,) .z
, -
Place of Burial (or Removal)-. ....,.v .. ... . --- ...---. . ,-,.. .. ,:-A-... . ...,
(If body is to be pemAporailiy he ,till Xyac• /
Cemetery -1-..-4 - , , 4 .•• Date of Burial ,..)-tA—naiv_...' 7 19
(If body is to be tempor illy hel :fill in up e'ter)'".. '
The Certificate of Den contai•in, the above stated particulars, having been presented to , after careful exami-
nation, the same appearing . 1•4-COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same or registration, have recorded it in my Local Record with the above stated Registered
Numbt_ ejoz.Lcmild ,,,,e :s.t thereof NsT A PERMIT Cy„
the 2 P Ez ,..z
,....,..4 ,
...t.„,..„..., c.„... ...,
to hold temporarily and. t body.
m perrn haying charge of corpse) • (In , e, e se Manor of[state how])
Dated (.49 19..67? (Signed
Local Registrar
This Permit i sufficient for the Removal (and Interment or Crem ti n) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in hick case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH IN` TS OR CREMATIONS
ARE MADE
Date of 7 t _ was 19. __
(Interment or Cre ion)
412-17-7
(Name Cometery, Crematorium, e to.)
Section Lot No. Grave No.
C:\(11),, .
(Signed) 9-
(Pern ergo)
Address l^rs G
i
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.