Haley, Julian Form VS.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr This Permit can im 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. 4 Registered
Dist. No2.1............County "--' a--,--r—e---,--- zitrcz.---b
Name of deceased /Lc-4 , t (If city, e street addMiss)
Veteran
,
(ti ,,teran, give name of War)
4,7y Single, married, widowed,
Sex Color (-/---1 or divorced (wnte the wor .h. .-. .. ...... . ... Date of --peath - --1.--) -(2--er--- -3 e,/ I9..6.
Age 55—Years Months _ Da Birthplace (----C--t,.--c-
Cause of Death- ,I,,,A7 -,e,--:— -s•--'-`--"--' --<-:—. ...-.-.-0:‘,...---0"L--.'
Certificate was signs by. /7-2 M.D.
Address 6---`//'---0
Place of Burial (or Removal) .-7..—:
(If body la to IM,Mmpo I eld,fill space later) /
(.../ ,
--- —2 67
Cemetery47-- .:.›..,-- Date of Bun 19
(If body is to be temporarily eld,fill in space later)
The Certificate of D th 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 ec d with the above stat egiatered
Num , and on the has' f I HEREBY GRANT A PERMIT
to. . ,....._..„----
_1 V
, a , -‘ 7C-1-11tdree,r
hold temporarily and ----, -9-,---' the y.
(U ertaker or person having chargy,of corpse) (Inter,remov or otheerise djeoope of[state bow])
Dated (----- ,a-- 19(.07 (Signed) 1,
, al Registrar L-L---1-14
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (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 INTERMENTS OR CREMATIONS
ARE MADE
Date of was oZ 19 6 A-
(Iterment or Cre on)
f /
�V it yy�
a e...e.....„.„.4.......4.,27----
(Name oi. em(etteery, Crematorium, etc.)
Section ` t ,Lot No i Grave No.
(Signed)1 /(,,
(Petiletof204r n in charge)
6aAddress 6 et 'We..,f."---
, r-,,,a2-,. '
Person in charge Heist 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.