Sanders, Leroy Form vs.6- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit eau 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.__.�..1,.
Village C '�'/Dist. No County. - »�-' or City
— (If city, give street address)
Name of deceased - :� ,, ee q, k-f Veteran
f j� Single, married, widowed, / r (If veteran, sire a e of War)
Sex..... .....i'Vl.....Color.... or divorced (write the word)..... :Z2 ve Date of Deaths 1.�. . 19."�.
Age C ....Years Months Days Birthplace -
of Death .4..::.,1i.- ! 1. /-
Cause ... . . . ... . ...
. . _ M.D.
Certificate was signed by . . ,:% � .
Address
Place of Burial (or Removal) :�"1 :( 2/
(If body is to be temp r rily held,,flll pace later) ,
Cemetery I ` - ` �' %: am, -Q- C 27, Date of Burial 2- 19 /
(If body is to be temporarily held,Ali in space later)
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 ac ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basis thereof � 1 Y GRANT A PERMIT
.,"-
/�- _ ame) (Address)
the ��Y� - ..,.:...�, to hold temp and the body.
(Undertaker or per sing charge of corpse) • (Int re o e dispose of(state how])
Dated / .. -19..�..t!.. (Signed). 7`�"�
Local"Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eubjeet 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 SEX1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
,
Date of '114y7r,' was "� L 19 I" r
(Interment or'E.e�e�isssao);
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) l2/%7 L
(Pero* 3n charge)
Address o � — co
Person in charge must return this PerMdtrto
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.