Bosley, Delia form VS.41L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q Thh 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 CERTIFI TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.r.l-.._6.4
_ Village
Dist. No `'/ County...»,,.../" / f.-P" or City .� -- - C
4 -J (If city,glv�street address)
Name of deceased vs� .r:%5.:... , ..: -)�-''�'' / Veteran Lc-'"
11,��//� Single, married, widowed //1, • ! (If veterap. give name of War)S n
Sex NT Color...1k or divorced (wnte the word)..,l.4`-=/ X-c-j- Date of Death _ / 2_/'7 19....
Age :/ Years". Months .......Days Birthplace ,'�6'.---' 1:2'-a- a t c7&
Cause of
Certificat ewas sign d byl...C..l:7. ::i ,�.t ' c.�: z:, ?,�
`/ L. l r t M.D.
Address .F .�.� .........17zE-(--Z., ,,
Place of Burial (or Removal) ...� z:�:.')! <, / % .x �- t-, -r -- �_ . ,,,. ,-
(If body Is to be tempo arilyihyl ,"11 spa
ce later) ,
Cemetery....„ - .......Lc.- �'L'L-'k.Z!G- -J .,-\ '—,�,�Date of Burial � ' c 19 51
(If body is to be temporarily held,till in 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and ou,the basis therof I HEREBY GRANT A PERMIT
to „4-' .l.:C'�'t .Llt:7::c:i.. `(Nr. .i-.-te"r:':.�s.G..t.G.i .�.:. .._.4-�. .. � f6.. :c /�=E:e ) (
ame) (eddread)
the Z�'vc-c^t; Cr.:. : <r....................to hold tempo ril anc , .� ':-.,. the body.
(Undertaker or person eying charge of corpse) (Inte re the se dispose of[state how))
Dated / -:' 14' 19 7 (Signed
Local Registrar
This Permit is sufficient for the Removal (and Interment or Creme ) of a body to any part of the State ("object 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 SN'X1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was . %0 19 j7
(Interment or Cremation)
(Name of metery, Crematorium, etc.)
Section l Lot No. (
egetrisli
(Signed) (\z-tJ
(Person in charge)
15-'
a4
Address V X
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 4
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.