Moon, Verna Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed wily by the Local Registrar (Deputy or subregistriur) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF ATE F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Ili,astered No ""
_.,....ryzole„,
Dist6.N5..ki.i..County.....4I . or City (. ..e.-/--Z'
(If city, give street addreii)
Name o deceased.... ' Veteran
(If veteran, give name of War)
_.,Single, married, widowed, , o
S ...... .Color..a4f4L..—.or divorced (write the word). Date of Death / 47
i ' ' 19
Age ,- Years/ 0 M nths Days Birthplace
Cause of Death ---&7-7
Ao.e...;
Certificate was signed by.... M.D.
‘ p•
Address
Place of Burial (or Removal) ..e--2.:54.
42.
(If body is to be teP5rarily hril, spa; later)
m Ceetery..„.e.L. Date of Bti al ' • .2 ii---
e
(If body is to be temporarily held, .0 in apace later)
Thn Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay ccepted the same for registration, have recorded it in my Local Record with e above ted Registered
Nu , and on the ha 's thereofI:FIE. 1..r2r.tANT A PERMIT
f
.--'
to../.,, .. 4i-,-1.7z.e..4 \7__ _-Nit ) .a.1.4.
( •
th to hold temporarily and E- --Z-- the body.
(U)l.drtaker or person haying charge 9:corpse) ' (Inter,7move,or ett7w1se dlio..of[state bow])
Dated t-7/ 19 .,/ (Signed) 4-...—.-
Local Registrar
This Pe t is sufficient for the Removal (and Interment or Cremation) of a body to any poet of the State (enbject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Peraut (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of a'Ol/We. A was 7/_. Z' 19‘f
(Interment or Cremation)
\.---fgameC Cemetery, rematorium, etc.)
Section--- rti, Lot No. Grave No.
(Signed)
(Pers 1 in charge)
Address
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 UN1,ERTAKERS
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.