Brothers, Jill Form V&aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ur This Permit V= 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.._/3,?'_.
Dist. No.. CV Cle&
.... � Village or City
Name of deceased .L.. )SrK.e}..r- . ..,!L� (If city, give street address)
Veteran �—e
��/ Single, married, widowed, (If veteran, give name of War)
Sex �7 Color....,CY or divorced (wnte the word)... ... . . Date of Dea .... ...i..I..,Si 194:9
Age Years. .. Months Days 7 'i'i�--r Birthplace ,. ....,~ 1.. .-z ..�1....�j
Cause of Death /
Certificate was signed by / .. .. M.D.
Address )l - y-
Place of Burial y(+ '- moval) ...I7tpi....— .... .c,.c-e.-4r>Gc� -��� J .. . k.
(If body is to be tem '• held,flp in space later)
Cemetery C°P. Date of Burial ‘. 7 19.474
(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 COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accep the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on a basis thereof ItilE,REBY ANT 6 PERMIT L
7.y.
�re� ,� '� (Address)
the „,...i. :k .Y.l.��..�t . 1 to hold ter r l nd 'G' the body.
(Undertaker or pe 7 4�haling charge of orpse) _ MY(Inter, v , r of nose of (state how])
Dated 19....- . Si e .
Local Registrar
This Permit Is sufficient for the Removal (and Interment or Cremati of a body to any part of the State (+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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o wJ 'e
(Interment or Cremation) 19k,.
J•
oe-A-/-
(Name of Cemeteryy,, Crematorium, etc.)
te -//''J
Section Lot No.2 3 ,U' Grave No.
(Si ed
(Person in charge)
Address 7
-SkC '17S
Person in charge must return this Permit W.
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, FUNFAAL 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.