Jalet, John Form F&6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered
Village
Dist. No County or City
(If city, give street address)
Name of deceased Veteran
Of veteran, give name of War)
Single, married, widowed,
Sex Color or divorced (write the word) Date of Death 19
Age Years Months Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body Is to be temporarily held,fill in space later)
Cemetery Date of Burial 19
(If body is to be temporarily held,fill In space later)
Thn 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 on the basis thereof I HEREBY GRANT A PERMIT
to
(Name) (Address)
the to hold temporarily and the body.
(Undertaker or person having charge of corpse) fa (Inter, em or_pth'erwi a dispose of[state bow])
Dated 19 (Signed) (
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremate ) of a body to any part of the ate (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 ;',J ,. was (, 19'J
-17
(Interment or Cremation)
(Name Cemetery, Crematorium, etc.) /J
Section I Lot No. Grave No.
(Signed) ars,.
(Person in charge)
Address �3 --�- ;
.}cam e , .
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.