Noyes, Harry Form TB.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lar 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 CERTIFIC TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 'jw— ,Rygitstered No._....._../.._ U :
Dist. No6 C6 County ✓mac. 'Z✓r�uti c/ or City '�..� i ,' c(-•' r1 f -t
1 2 . (If city, give street address)
Name of deceased .4rL"it" L' .y� ( cti � Veteran
1'v Gd — Singe, married widowed �., p fl (If '"`"an. aim` name of War)
S Color or divorced (wnte the word) 0 lJ--e.X�r Date of D th 1 4"� " -� 9
Age 7 Years 4 Months :-..^:......Days irthplace...../. ``.z Y
Cause of Death -t—t =' ��n4C�' 'e /��' �" r_
Certificate was signed by `-- . d v { ,,L� i ` M.D.
Address �} - /y�7..C7- , ,.c �/v, r � (,-- a(eL
Place of Burial (or Removal) i,�-�"' 0 -�c-c-`'— d' out
(If body is to bytlmporarily held,fill in pace la Per) —
Cemetery ri<� d--(x-A.ve�"` I a`."1j E^r(- ti .:Date of Burial" 19...
(If body is to be temporarily held,fill in space later) s
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 alre stated Registered
Number, n ,the basis thereof HEREBY RANT A PERMIT fC-
to f ,A_,-vr��r,t r w U �, c,--le `ti
(�
the ��� `"�) to hold temporarily and.... .' (Address)
�`
the body.
(Und maker or peraQn baying charge of corpse) (Inter,remo ,o othe se disgot�L how))
Dated �1h-" > 19 S 2 (Signed) ���LN "�• ••
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o a to any part of the State (subject&I/local
cemetery or other regulations),unless removal is by common carrier, in which e a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS CREMATIONS
ARE MADE t 7,- /
VI ‘,e,e,ie41,4 /
/' r
Date ;72--".
r, 1
(Interment or C emati )
„7/..)' 7/ - Zq ,,,,-)
G (Name of Cemetery, Crematorium, etc.
Section (2 Lot No. ? Grave No.
7,--Zei,7
��:L� 'e/41
(Signed) K„_____ d%,z(Person in charge)
Address �� k. 5‘7-7/1,-2„2,____-'.'
-C'�L
Person in charge must return this Permit to 1/ ,
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 STATFr
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.