Duggan, Leona Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.'4 ..._._
Villag y�
Dist. No County:..:..%-mot 9z-z.ti - .. or City t.�_-c -e. - }---ee cif
(If city, give street address)
Name of deceased t :k4G .... . A/.J ii.. t-4- .. Veteran
(If veteran, give Ere of War)
-Single, married, w w�ed,
� Gt. - c Sex4Color. .or divorced (write the word) 24............Date of Death.,.., ....1 0 19...a
Age.... i Years Months D .??L. -ys Birthpiace ' "Q'? )c, A
Cause of Death .r... / ... t.t:t' ::yi .7,.. .. `-,--'1tiat.4. } I1.
Certificate was sigxted �...1.,. . ... .. ✓ / l RCt... M.D.
Address rT :5— � �G, . ' y.4e. r
Place of Burial (dr`Rem va1)/ ... ( `11L.
body rely fill m space I ter) c /
Cemeteryato be m ors af^ ' �� -u-.J"��`...".J......Date of Bura .. ...1.. 19 C'r
(If body le to be temporarily held, fill In space later)
particulars, havingresented to me, after careful The Certificate of Death containing the above stated been p
exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a pted the same for registration, have recorded it in my Loca Record with the above s ted gistered
Nuto. ber o / e as}'�;-thereof I HEREBY GRANT A PERM T )- /�/�
(�ttae) (Address)
...i�„�„ L Q::(�'m to hold tempo rily and... the body.
M*IcrSster oy -�
erson having charge of corpse) (Inter,re.` ' ; ,s. - dlsoose of jig*how])
Dated..G:W. .ti.. ' .(...,. 19 (Signed) ... �.'5'.;(2.° - .:.I.L....f-2-2,t'.G
• al Registrar
This Pert is sufficient for the Removal (and Interment or Cremation) of a body to any pest of the State (.object 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 PEIMN IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRE►1ATIONS
ARE MADE
Date of was 19
nteraent or Cremation)
_yam-.42"4'i.-.-.
(Name of Ceae ry, Crematorium', etc.)
Section Lot No. Grave No.
(Signed) u�///l •'/ (t.A-A ) 7.
(Y�iraon in charge)
Address G !.
Person in charge mist 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.