Paul, Isabelle Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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.__'.�.._r.._._.
Dist. No County..._.... j��--2--).--r--
or VillCaityge ��
(If city, give street address)
Name of deceased 1 6-e-r G7-7T 1 Veteran -,'
Single, married, widowed, (If veteran, give name of War)
Sex....., Color....., or divorced (write the word). Date of Death fi 4 ' 19..C/
Age 4:.....Years Months Days Birthplace -� �.1 2z
Cause of Death (..°A 7 c am-:tea
Certificate was signed by.. r_i' -.5A :. . �-7- � ..1 -e- M.D.
Address �-���.��r_ 1 . `�j- .�...... /57
Place of Burial4oar Removal) 7 ;;r J �, �'z y L`
(If body is to be kem arily held fi in space later) L
Cemetery r nr '4 Date of Burial
/
' v _ /
/„( 2 3 19 67
(If body la to be temporarily held,fill In space later)
Thq 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 Record with the above stated Registered
Number, on ffie psis thereof I IEBY GRANT A PERMIT
to ........ .. 'vT2, ''�rrzc.; - k� �."--f .•.�
�' ( me) (Addre
the 4f- {-T to hold temp rily d the body.
(Undertaker or verso aria,charge of corpse) (In re ve,or e o of[ tate how]
Dated j 2- J 19.:..,.... (Signed) ..,./... ' ' - --Z
Local Registrar
This Permit is su cient for the Removal (and Interment or Cremation) of a body to any part of the state (.abject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSB1ENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTS OR CREMATIONS
ARE MADE
Date C,2;;__.7/4!i/Iti,t4./
was 19
(Interment or Cr tim)
/:.
v� -�.�-�
( awe of Cemetery, Crematorium, etc.)
Section Lot No. /76_ Grave No.
(Signed) ,.yG
(Persod in arge)
Address �r
I
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.