West, David Form vs,O. 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 a:.nd acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.I%%_ ._........_
329'�` t>�EID Village ICY
Dist. No County or City
(Zr city, give street address)
Name of deceased ,.� ...t9..11.z. ........L)..e..s�- Veteran
(If vetersny give name of War)
Single, married, widowed,
Sex Mali .Color 'White or divorced (wnte the word) Married Date of Death '4' 19 ef
Age Y rs Months ,....Days 1 Bi , place Lak Geerge,,,f.New York
Cause of Death... e .. Y.:l. t L.0 t t,i ,n.G .eky....G. :A- ::c-.i 2Z- C:. r,..! -.4
Certificate was signed by 1/441 C. .'4 /vs i M.D.
Address .. 4 As.1t ktet f '7 /V•)",
. '--w `a z._ ... -.,, ��.Place of Burial (or Removal) .:. .,r;- ,..-� �.- �
(If body is to be temporarily held,fill in space later)
Cemetery Da e of Burfal. ..z - 7 19. .L
(If body is to be temporarily held,fill in space later)
Tht Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same ap earing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted same for registration, have recorded it in my Local Record with the ve stated Registered
Number, and the eta' ereof -HEREBY GRANT A PERMIT
. e j/
r._-_... (N ) (Adel
the ••� e�+-"� +L`----- � to hold temporarily nd �,:.L' the body.
( n ertaker or pe a haying charssp� corpse) (Inter,rem,vve,or othe dispose of[state how])
Dated.... . ..Q.t. '�' 19kl. .. (Signed) 77 . �`-G( i... ... .at- -,-
Local Registrar
This Permit sufficient for the Removal (and Interment or Cremation) of a body to any pert 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. i
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was ?< <- i 19 tA�
(Interment or )
(Name of Cemetery, Crematorium, etc.)
Section.-- f 2 Y Lot No./ ..fT‹ Grave No. 7
(signed) (e,-:2
(Person in charge)
Address C' //�///h1� �/ S.y"
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.