Billington, Rose Form vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
L 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. Town Registered No—__................. —
Village
Dist. No County or City
(If city, give street address)
Name of deceased Veteran a
(If veteran, give name of War)
Single, married, widowed,
Sex Color or divorced (wnte the word) Date of Death — 19
Age Years-- Months Days L . Birthplace 2 14.je
Cause of Death
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body 1e to be temporarily held, till in space later)
Cemetery Date of Burial /
19
(If body is to be temporarily held, fill in space later)
Thq 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) (Inter T o her 41. e of'[state how])
Dated 19 (Signed)
Local RegistrarI
This Permit is sufficient for the Removal (and Interment or Cremation) of bod to any part of the State ( .ject to local
cemetery or other regulations),unless removal is by common carrier, in which c 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 w '�/G2�`t�• 19
(Inte men t or Creme ion)
`' :6(12/(xt_l, (Zt71/-4
(Name of Cemetery, Crematorium, etc.) J
Section Lot No. 2 Grave No.
(Signed
(Person in c arge)
Address;1f iV. ✓ %
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 DIRECTOF 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 reiaf,ive 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.