Baird, Thomas Nom TOL 41. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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—.4....................
Virtg:e --)
Dist. No .5-- --/' 57County.....h1.2a.k.1...41/ or City ....,---e-e-C(...: ''.:.k-,-...77...1.. .., ''.1
''?..... . -.1.If..city,give street addre
Name of deceased ----ti.--P.-./z.-Z.c.:‘...:0 -
-41 /V 'K Veteran 4;---e
`---/),Single, married, widowed, ,
i
, -n (If eteran. give name of War)
Sel.14.1.4/. .. lork. ,44...or divorced (write the wordr.-.21"&44- Date of Death f' i:. ,
Age. 2 Ygars
to
. Monthss,..A. Days , Birthplace...
Cause of eatIC: 444.4.a ".egead:1‘4-041A.. ..crl '2'ev-a4toti: %Gill:. ...4‘.-- --r-lo.-krdari-i,..e-
/.. - ' •-•
Certificate was signed by .. , 21 2. M.D.
Address. - -e-144-7.--/7 . ..
Place of Burial (or Removal) e , ../.---...........
(If body is to be temporarily held,gill in space later)
Cemetery `742.4<1.-4 <7 (i3st ...-;:.Z..-4.. ..,r,-...:-:-- IlDate of Burial .//)--,7V 1 9.4.7..
(If body is to be temporarily held,All in spacelater)
Tha Certificate of Death containing the above stated particularseving 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 Lo I Record with the above stated Registered
Nu4a. 7and on the bash, thereof II HEREBrN A PERM"..443
,../Le.
to..eir:;::::-.--3-fe4Z...1.a..,./. ../.4f.i../4,.. . ..,ii---:(7—• . , , . ,,..0--,.."--03;:r:7700.er7, ..."7-e
the....;/ 11%‘ 44Fr21) i'',/' if 76- ii•e-p--,
to ho tem oz<Ay and. ddress)
--"' Le, 4, the body.
CUnd kerrierson having emus.of C ) Vz. (ISe ve,or.otherwise disoose of[state bow))
Dated i i"
/4
19.,c (Signed) ,--C.,-0----..p,
,„, al RegLstrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
-1
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
C
Date o2 CS ``� was 19
(Inter ent or Cre ion)
(lase of Cemeter , Crematorium, etc.)
Section Lot No. Grave No.
(Signed) ��l�s -- 0/ C .2.� 'C_.
minims in charge)
Address
Person in charge waist 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, 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.