Prounty, Mary Form VLSI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit tan be signed only by the Local Registrar (Deputy or aubregistrar) 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. To Registered No 3..6_(�
Dist. Nod 6 0/ County n e. •�� or City p/c4....e4
' 1/01(II city, gtstreet address) '
Name o deceased ‘77(Ca .. ..... ,... Veteran
Sl , married, widowed, ([f ye ran, give name of War)
Sex.. olor or divorced (write the word) .. . .... ... ate of a
Ag / 6 Years onths Days Birthplace 4r- . f
Cause of Death if/.. . ... .... ...... ..
Certificate was signed y... .. M.D.
Address , f"
Place of Burial or Removal) ,„
(If body is to be •-rarily held, 1 in space la er)
±"1-4-''--tlPe""""gz-
Cemetery.... ,.-.f�- rs,..0 Date of B al ., .. — 60- 1947
(If body is to be temporarily held,all In space later)
Th4 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
Qstated Registered
Nu , and on the basis ereof I HEREBY GRANT A PERMIT c� p/J
to. �� [�
ams -✓ ress)
the to hold tempo ly d the body.
(U maker or rson bars charge of corpse) (Inter,re overor se nose of [state bow])
Dated.... 4 19...S. (Signed) .. ....
Local A
This P 't is sufficient for the Removal (and Interment or Cremation f a body to any past of the State ("abject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEX'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date h L� 19
anent or CCremati )
. ? ........e.t. "---,/..1.,_ _ ..._............_.,
/72---) &
L.,/ (Name of Ceme ter rematorium etc:
Section Lot No. 0 Grave No. l
...:7"...77 , . ,
(Signed) , % ' LfA
Wiz- ./
(Person in charge)
•
% r /AddreSS ( `, / � •�4 ,�� - am � ` J
!
Person in charge must return this Pe it 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.