Farr, Milford Form vs.el- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 CERTIFICATF OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._...._......_._.....
u Village--
Dist. No'- ' County or City
_ (If city, give street address)
Name of deceased r��"C' Veteran
Single, married, widowed, (IF veteran. give name of war) _
19 `r
Sex ,:..�.7 ....Color..., 'or divorced (write the word).., •..C. if�'�P Date of Death
Age ,�):. ' Years r Months Days Birthplace ' �c './' -`r
Cause oTDeath ...... ..I:.is; f..,i I ` ' , .,
Certificate was signed by .; <.z.. r / - -( /J4✓.,/,..c.rti/ ,. 3- M.D.
Address k(;al ,:e��J--ui � 4 ' yI-/� k.G ,
Place of Burial (or Removal)" { t ///'
(If body is to be temporarily held,fill in*pace later) / i 'r
Cemetery , Date of Burial /--f-'(- G/ 19::Jr,
(If body is to be 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 MPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for r " tration, ha ecorded it in my Local R cord with the above stated Registered
Number, and n' the basis theIRE,�Y�RANT APERMIT/ " r ' `
' ,4-‘-'--t--.1,(- - < "-/ ( t-f f .-./e- 4/-(-Z
/ 14 Address)
the...., .;4 �-' ; ' l at to hol temporarily-awL 1�.S:-t:-- the body.
( derta or person Aag charge,ofcorpse) ante .`remo'e,or other-wile- of ja i howl)
Dated.. (,.L. .(. r i- 19 j (Signed) ` a ,: r� .....: %::�.
/// Local Registrar
This Pe ' is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or er 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
PREMISES ON WHICH INTE BENTS OR CREMATIONS
ARE MADE
Date o J was ' , 3 19 /
(Into cent or 'Cr tion)(
7. 6____•"-2)• A I.
� Nsse oz Cernetory , Cron&torius etc.
Section .Q2� ' � 'No. Grave Nu.
(Signed) 0-2y462—&r "469-4 �,�{
(Person in nkorp)
Address (D ai1` `ii,, � .// Vf�
v i/ � �•
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 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, FUNFtAL 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.