Combs, James Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t_ 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No. ..............-
Village
Dist. No I County or City
/ (If e..t , give street address) �-
Name of deceased ,�.¢ (....:---2-,,-- ---�- Veteran ,e
, , ngle, married, widowed, (If
`" give name of War)
Sex. olor...,LN� b'divorced (wnte the word).. Date of De (Z-- 19-7
Age...4' 174 Years Months Days Birthplace.... / '
Cause of Death P..
:Certificate was signed b� .. . M.D.
Address. �j '
Place of Burial (or Removal)..! z., 7-7 -, '
(If body is to be tenipor&rily held fill in space later
Cemetery...., ::1 a: '- -/ Date of Burial /. 1937
(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
Number, and on the bask,thereof L HEREBY GRANT A PERMIT --
(Name) `` � (Ad s)„
and G' the body.
the to hold temporarily Y
(Under r or person baving charge of corpse) (Inter,remove,or othe diso a (etats ho ])
Dated / i9.. .9 (Signed) ..-.
Local Registrar
This P rmit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the 'late (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 SJ XiON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTENTS OR CREATIONS
ARE MADE
Date o 4--"lam-` was -'2. • /5 19
(Interment orCre tion)
----e- '41'.--.1---(1;-- '1"--1-- -
4..., r7l ,..
(Name of Cemetery, Cr matorlum,_ etc.)"......(eee--rc...g.2-.-i.e.,' 4.-,,• i..)
Section Lot No.Ar Grave No.
7 ..
(Signed) (1/ -L
(Person in charge)
.-- ..= , _,_ ,
Address, ..,
-�ff /(
Person in charge must return this Pe • 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.