Milne, Oswald Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
LI: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.. Registered No._
Dist. No/&/ County.. Village-
or City
(If ety, give street address)
Name of deceased.. Veteran
�`` a married, widowed,
(If veteran, give name of War)
Se :C ..Color . 1` or divorced (wte the word). Date of Death.. Z��....19... ...
Age ..........Years Month Days Birthplaces.... b..4•x',Y.`? ...
Cause of Death ` ei.- -4,�r-— --ter j :-� N
Certificate was signed y M.D.
Address --�...�--�-�=�-�—..:���� V/� �1 v
Place of Burial (or Removal) '�. .,`..„r - -- ; 1 4. f
(If body is to be temporarily 1 held,fill in space later)
Cemetery Date of Burial.. 19.�,...
(If body L to be temporarily held, 811 1n space later)
Tim 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the s e for registration, have recorded it in my Local Recor with the above stated Registered
Nwsiberr-and on this thereof I HEREBY PERMIT
t ......... i'(Name) —
Ad
the r_ to hold temporarily and the body.
nderta er or rsoa_�=ing charge of ) remove,or oche Mario Is to ho J)
Dat 19 (Signed�� ,�!L ,.Gf-��?' .lF 2 r
Local Registrar
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 SOMA OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
9C
Date of �> C....4..4!' was' '- 19 1
(In rment or'
(Name of Cemetery, Creme'toriva, etc.)
Section Lot No._41.40___Grave No.7
(Sigeed) f /'�irl� "'-.,::., '.(Ve:eec. 667
(Person in charge)
Address ,,,:„_,..4�=Ga.-�^.����-�"
... ' j�/
Person in charge must return this Permit,Ao P
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 %TENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.