Hammond, George Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t! This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI T/
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town �Re istered No.__..-.. -. ........
in which the
--7 I Village
Dist. No�' � County `1 T. �: - - .,
• ..:� or City z- t (P '
.// city,g e street address'`
Name of deceased , 744.7.. er ///"' Veteran �`
r,, Single, married, widowed, (If veto an. give name eLWs )
Sex..:: .... olor �� or divorced (write the word) (-• l --' - Date of Death -- `� 19 �
Age Years. Months Days Birthplace t -Y
Cause of Death -� ` e /4
Certificate was signed by t� M.D.
Address 4.m
Place of Burial (or Removal) - ('• - .' x
(If body is to be temporarily held,till,*space later)
Cemetery -`11-�" - .r. , .,- Date of Burial -- ! tC 19.6.7
(If body is to be temporarily held, fill 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 accepted the same for registration, have recorded it in my Local Recur -with the abovs stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT /0 6
__... - ..„ .,_.) rfiai
the to hold temp arily ncL . ' the Y.
(Undertaker or person having charge of corpse) (Inter,re e,o di .ose of[state how])
Dated ,.r�:.. ,. 19 (Signed '�1.r --
c s'f ( is Local R
This 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 INTERMFNTS OR CREATIONS
ARE MADE
Date f A- at" 2 X- 19 t /
itlif&ment or "Lion)
ti,.ryl Zit. v�-
'Mane of/41' tery, fresatorims, etc.)
Sectioifi(-'�' `t. of Qo. Grave No.
(Signed)
(Person in charge)
Address v e 'ay 0 0 id,_,,,..,,ate.,
, )1:47/
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.