Anderson, Robert Form VS.gL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered o. _
,.i i Village
Dist. No,:z......1..County...,��1...111. ,4:.......r or City ::.l a. .,.
(If city, give street address)
Name of deceased. .1.. . 7 ..P_r.... •••• .. . Veteran
veteran, give name of War)
,/�r Single, married, widowed, 1
Sex . .. . Color. f.Xlk.��or divorced (wnte the word).. ., .t.Date of De . ...19...ri
��V
Age..../.2. �..,..Year Months `........Days �/ Birthplace.. sL.,4Pa.,.)1
Cause of Death.. . .... :.$.
Certificate was signed , 1 • p� M.D.
Address % ,r r,.,e cee C .,..Q,o,...
Place of Buri 1 (or Removal). i. !`,
(If body is to mporarily held fill in space later) a�
Cemetery... /--- ,,, ��,.ttd.c:- 221.e. , Dat of Burial ,/. e' 19.,ra./
(If body is to be temporarily held,fill in space later) 7
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 on the b tO ia�I +IERE Y GRANT A PERMIT.....Cs. . ,?fi-.etZef
the -te to hold tempo 'ly And ... the body.
de ker or person tng charge of corpse) ' ,(Inter,r ov s nth gnome of [state how])
Dated.. .. 19.. ./ (Signed) . .1�Z--. —a----
Local Registrar
° Permit is sufficient for the Removal (and Interment or Cremation) 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 INZERNIIdTS OR CREMATIONS
ARE MADE
Date of •
4,. „. was ,< � 7 19 I /(Interment or or'Crq*tian) ..r
1
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) ! % <y ... //,:
(Person in charge)
Address 6//-6, - //o ��Z / Y
Person in charge must return this Permit tooy
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF 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.