Ricketts, Martha Form VS.6L 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered No—
Dist No ' .'-.)./..county.., :doct:-.1.--k-z.—.
(If city, give s K
. -
Name of deceased . . . : z. Veteran
----
/ Single, married, widowed, (If eterap, give name of War)
Sex. , Color.,24'. or divorced (write the word) -(.. Date o/f Death
_ i
Age.. /7 Years..(, Months ... .. .Days Birthplace..L.e4..,.. ‘.4.04.i.,.—.- S
O.Z
/
Cause of Death .
Certificate was sigped by,........4.4 ' : ..
M.D.
)
Place of Burite (or rliempvdal)?
(If body is to be ora y ,fillin spa later)
Cemetery ,,. .7.-a,.. .-e....v...:1 ,,.. Date of Burial '.// 19 61
(If body is to be orarily held,fill in space later)
The Certifi e 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 accept the same for registration, have recorded it in my Lo Record wi the ye stated Registered
I
N , - tbp basis th7f HERWY GRANT A PERMIT, '
(Le; _ 22?
, .46...ddressi
the tr. to hold'temporarily and ... . s ' the body.
( er p-person having chargefif gorple) --'' -. (Inter,re or. mil*cllanoseofie bow])
Dated i.'w> 19.4D7. (Signed) -.7 ,. .-.t4C....a...41. ,....<'-'
Local Registrar
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (.nabject 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 INTERMITS OR' CREMATIONS
ARE MADE
Date f' �L�C�"z=� ..! ..., `/lc' 19
(Interment oT°®fodirA2an
lc..•/ J
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) / (J ` �G e:-/ . -.e
tt (Person in charge)
Address - ✓r, 16 - `
a
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-
RENT, 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.