Harris, Flona Form vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFICAT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Ica..+
�..,_ ___ Registered No .7. ._
�� i Village ______ _4.......v........., ,-
Dist. N -�.6 /..dC County r( c'--'''— -,-- or City -
1 (If city, g street addrel
Name of deceased 4`�` - Veteran
Single, married, widowed,
Of veteran, give name of War)
Sex.... . Color or divorced (write the word)w�� Date of Death Jr / 19..&✓.
Age.. r g d Ye Months .. _. ays Birthplace
Cause of eath . .. . .. .. .
Certificate was signed ... �� M.D.
Address ✓
Place of Burial (or Removal)
(If bodyis to be temporaril Jill in space late
Cemetery .'- . - Date of Burial.... 4 7for 19.r'O,
(If body is to be temporarily held,Jill ins ce later
The Certificate of Death contain ng the above state ' ulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORR CT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for re.; tration, have recorded it in my Local Reco with the above stated Registered
Nu bit don a ba 4he di I HEREBY GRANT A PERMIT GL, /�/�
..... ....... ...
( (S as)
the to hold tempor 'y rid ody.
(Undertaker or person-baring charge corpse) ` (Inter, re e,or ate en se state bow])
Dated 5 / -., 19..61 (Signed y,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any part of the State (enbject 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
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date,of''/; was— 7& r/ � 1,9
(Interment or Cremation)/ T
/ rr
Cie
'))
(Name or Cedaetery, Crematorium, etc.) "Ti
Section Lot No. Grave No.
1 7,1
/(Signed /'' -Glr %^-,.
(Person in charge)
Address
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, 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.