Hewitt, Gerald Form vs.u. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1r 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. XEY9I71 Registered No—.._...__....._._
Village
Dist. No County or—E - ..'7,ee i_ G
9,,,,47, /� �� ' /LG� y (If city, give Ft t address)
Name of deceased ` '��` Veteran
Single, married, widowed, (If veteran, give name of War)
Sex 2 Color Li) or divorced (wnte the word) Date of Dea ~' -z ! / 19 6'
Age c Y ars M ths Day Birthplace er )2 "
.
Cause of Death /1Z.� L,<"c'`"r /
Certificate was signed by ? � 7 ..�.�/G M.D.
Address. ,r' t "���XX�- q �7 <`
Place of Burial (or Removal) ....�/: .ra' Gi��I1. � � iu'Ze P �1,.,
(If body Is to be temp held, U 1a spec lajs 1 -
Cemetery !!GI ..,e12 t �?� s Date of Burial .. 19‘1..
(If body is to be temporarily held,fill in apace later)
Tht;Certificate of Death containing the above stated particulars, having been presented me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept the same for registration, have recorded it in my Local Record with the above stated Registered
Number, ,op th i aisithcreof I HEREBY GRANT A PERMIT ,f
to u.2 L.. . �.f //n.'�C�� 7. ` �
(Name) (Add ss) ,
the 7G7 ' to hold temporarily and...., the body.
jlqndertaker or person having charge of corpse) f ; (Ioter,.,remove,or otherwisedisnose of[state bowl)
Dated.. 7 `-/ 19..6 Si ed ,...(:.. ,. �" t i 4 r.<. f i<
� / ( ). , / Local It
This Permit is sufficient for the Removal (and Interment or Cremation)f a body to any pett of the Slate (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 q sG2 `"I-;1. / was 6, (' 19
(Interment obi
i < <'n( 4/4_ C f['m-k--6--ze- •
(Rasps otCenetery, Crematorium, at�.)
4-7 ,,,--1:4 .
Section Lot "-I /-' Grave No. ->
(Signed) �t< - 1:"---%" C z�?'"L L //
(Person in arise)
a 7
Address !� p /r /41.1- j % -< - d//
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,
RENT, 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.