Reynolds, William Form vs.(IL 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—
Village
Dist. No. .........County...... .. - or City 15r- )97
(If elty, give st address)
Name of deceased. .k.i.ea r Veteran
or
Single, married, widow . ,...e., (If yet7. give name of War)
Sex * Color or divorced (wnte the word). ate of Death rc."---- 19 4/
Age et? yiirs Monti* Days Birthplace ..),1 .
Cause of eath..
Certificate was sign d by.. ....igri,„••••' . M.D.
Address
Place of Burial (or Removal) .4404..ek.ZrCr.X.4.7. -77 --24,-
-7- ,
(If body is to be temporarily held, lin spa later)
Cemetery..
(If . .. Date of Burial
(If body la to e e porari y h&c],fill In sp ce later) ,--
Th4 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
Numbej, and on the basis theyentA HEREBY GRANT A PERMIT
to . 1(Name)
. .
the. (Name) 42..(=.)...)
to hold temporarily and the body.
(Linde r or-persos-hirritig charge of corpse) ..•...— 3per,re ve,..or otherwise die e of[state howl)
k
Dated (•154//4" 19 (Signed) ../-
..0,
Local Registrar
This Permit/1s 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 currier, 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 .of/27 7! was
��ll2 I';"��- 19 ;�
s¢(Interment or-CaeOlan),! /
(Nape of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)/�--Cpc ' - v , / ' .,''--2. ._- G
(Person in charge)
Address (s/ C i if 14 L _ -VT—j ft&
//
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.