Busch, John Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 CERTIFICATFyOF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._.-. ..3..
4.Coup y. Village �y�
Dist No 4 ty... or City ����% zT" ,.t
p (If city,give street address)
Name of deceased , ..Q -?2- l � Veteran
Single, married, widowed, (If veteran give name of War) gg
Sex...�4.I1 Color or divorced (write the word) c .4 Date of D ath..,... ..ti: 0-7
Age Years Months Days /02 Birthplace....— . �- /.
Cause of Death
Certificate was signed by •...- ✓ .ti'i M.D.
Address ,:�,,. 1. i0
Place of Burial (or Removal) ...rt.W"l �1,,�„,,�.r„ ,e -7•-ew•- / •y.
(If body 1s to be tempora eld,Sit'Yn p e er) �f t
Cemetery . ........./ / '° 6 -ti_
c� ,l� v� Date of Burial j/..� 19...,�.
(If body L to be temporarily held,fill 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 a pted the same for registration, have recorded it in my Local Record with the above stated Registered
Number on the bag i thereof I HEREBYT A PERMIT
/
to .4444...P`.�. ' . �:r:ter' I. .. �. ,,..... �.. -
��r m (Address)
the G 11� •• ...,c.f� to hold temporarily Arid �' -a�C'y .i.,', the body.
Dated (Undertaker r gee p having charge of corpse) - (Inter,rempt►e,or se die eie o (state howl)
19. y1 �`�.s`' (Signed)�;�.� '—�-`t..:�-�.-t�:--:..r�:•�[..,:.:� ,.' .
Local R
This Permit is sufficient for the Removal (and Interment or Cremation a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in whit case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX ON OR'PERSON IN CHARGE OF
PRFMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 14. s 7 19 17 -
(Interment or C�e on) •
84-1"7.-..44 .7.
(Nerve of Ce tery, C torium, etc.)
Section I Lot o. Grave No.
Cd1(Signed) p"04L;E;41A-C1
-(Person iii merge)
Address V - 6 , / 6 0_0 - ...,_ e4,
tr
Person in charge oust turn this Permit to .
the Registrar of his Distric within SEVEN (7) DAYS
from above date. If no pers is in charge, the MUST SIGN ABOVE STAT
FUNERAL DIRECTOR or UNDERT R E-
WENT, write across the face f the Permit the words
"No person in charge," and Aril
PERMIT WITHIN THREE
(3) DAYS with the Registrar' f District in which
cemetery is located.
SEXTONS, FUNERAL DIREC `RS and UNDERTAKERS
violating the- law relative the return of permits
are liable to a penalty of N T LESS THAN FIVE DOLLARS .
NOR MORE THAN FIFTY DOLLARS R THE FIRST OFTFNSE.
The law will be enforced. al Registrars are re-
quired, under penalty, to r rt violations thereof.
1