Smith, Effie Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit T.-an 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—_. .'d..
��ii Village 4414_14,
... '4%Dist. No b U�..County..._...��ef:.�,�rr— or City
� (If city, give street address)
�-ff
Name of deceased r4r f ��z' Veteran �co
i-nt le, married, widowed (li vstern give name of War)
Sex. 7. ;Color. . or divorced (write the word).. Date of Dea 3 ...�1.‘ 19.,..):: •
Age ,7ja Ye rs Months ... . ..... ays_ Birthplace o/ f7
Cause of Death .. .. .. ......
Certificate was signed .. . . . .... M.D.
Address 5.- .., )7 ..,
Place of Burial (or Removal) v7 h
(If body is to be tempor rily held,d,l}�space later
Cemetery 5. .1.1.. 41 Date of Burial 19
(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
Ka Number, nd on the basis. thereof I HEREBY GRANT A PERMIT
lifeAr
the �. . . I ame)_- to hold temporarily and ' (Address) 7 the body.
(Undertaker or person hexing charge of corpse) (Inter,remove,or otherwise disoose of [state how])
Dated 0� 19... .:7 (Signed) Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the State (subject to local
cemetery or other regulations),unless removal is by common currier, in which case a Transit Permit (VS No. 62) is required.
(_" -R-�---
C°�z
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH IN WAD TS OR CREMATIONS
ARE MADE
Date o ' was /` ZG �/ 19 J� �.
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No.( 44 C Grave No.
(Signed) �GL��/ �—
(Person in charge)
Address GGC---2-l; a,L,
Person in charge Deist 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.