VanDenburg, Lowell Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ix' 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 FLUNG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__J...
�G/Coon v� Village. ......`�..� .
Disc. No ty..._ :���:�?:�':��" or City �. .f....eert.--'
j �:� 1; (If city, give street address)
Name of deceased..... -. ...,/ ... , Veteran f
�, Single, married, widowed, � (If veteran, give name of W.r)
Sex. ,[.Y.� Color 1t or divorced (wnte the word)�..1 Date of DeeAt,_ ' Z 1 .lp./
Age Years ,a 7....Months Days Birthplace...,.1`,,.,c' a .. ' .f l .....
Cause of Death .. - z
Certificate was signed by C 2?, M.D.
Address ,..
Place of Burial (or Removal) ) A&n-x7 ..ti,: ,/( Y 'f,-27 ;,z
(If body Is to be tempora y held fillls later)
Cemetery z_ zv2-cc� 2-72 Date of Burial j,� 3 1967
(If body is to be to porarily held,fill n 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, slid on the basis th f I HEREBY GRANT,A PERMIT .. ,
.4.44 .-4-.1-.c....`-X .,/,/...‘:a--...1,4A, "---:r--s.... - ••-&-g °v7-ea.,e‹./. 7-/-:
the (Address)
to hold tem$er�rily and the body.
(Undertaker or pe hyaying charge of corpse) (Inter,rempfe,or se [state howl)
Dated I/ .. 19 ,--,:: (Signed' - -' �istrar Zc.. .. .. .
This Permit is sufficient for the RemovaTr'41-'
Rer
(and Interment a Cremation) a body to any pant of the State (stbject 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 INTERMENTS OR CREMATIONS
ARE MADE
Date of ,ti�4 i..,,;._��_ was -j_- ,3 19 E,
(Interment or Cremation)
(Na of Cemetery, Crematorium, eto.) /
PR J 4-ST s L A�✓� 1
Section A Lot No. Grave No.
(Signed) . (2C� 64-'024/C.14
(Person in charge)
1 ,
Address •A,r (
•
Person in charge must return thls 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 OFF'LNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.