Unknown Form vs.iI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 CERT'FICATF OF
DEATH, LEGIBLY WRIITEN IN DURABLE BLACK INK. Town Registered No.__.._.,,(f..u'._ _
Vill Cl C
Dist. No County...... - ./›- or City-
7 `—' ��(
) 7, ) //�s (If city, give street address),
Name of deceased'` - ..ee -� - __Veteran �
Single, married, widowed, /..,�..1,I 4 veteran give name of War)
Sex .2 olor,.c- or divorced (write the word) '�'�' f "`' Date of Death 1-.... ' 19. '..
Age. ears Months Days Birthplace C.f:� 7 'a '
Cause of Deathy ,... . '"`'
Certificate was signed y ' rw- M.D.
Address f.i.. :... 2 ...y ,,...1.
Place of Burial (or Removal).... .. ...(.! l�E - c 'y,
(If body Is to bA mporartly held,91l ayface ter) ‘ �i
Cemetery ,�✓.. zs �...� 1'tl , Date o Burial L C 19
(If body is to b temporarily held,fill 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 on the basis thereof I HEREBY GRANT A PERMIT ,
to G' �Lrtl � t ., .
(Name) ('yes) ��C
the...% .Gs: to hold temporarily and VA' the body.
( ertaker or person having charge of c (I r,remove,or�her m wise diose of[state how])
Dated.. 19 Iorpse) (Signed) t{s.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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
PRRfISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
132
Date of ('du was 19 ‘.3 7
(Interment or Cremation)
7 -: i ( _?
_:/// ,
( - (Name of Cemetery, Crematorium, efic.)
Section Lot No. - Grave No.
(Sued) % / Z'y c _ 7 3.4
(Person in charge)
Address � � : ..-[�_ ('
Person in charge Heist 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.