Brown, Ashley corm VS.aa. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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.___�.,f...,2...7_......._
Village
Dist. No c-�G d!County.. 4:aY.. : �2 'or City
(If city, give street address)
Name of deceased 7(i?!C.� Veteran � _, - X
PK
Single, married, widowed, /� (lf v eran. give n e of w") /Sex /•Nri Color or divorced (wnte the word) )�?&11 i Date of D /..?d 9.11.
Age (� Years P Months D,Days Birthplace ,�.yr.!.
--q,
Cause of Death --Ai
Certificate was signed by... . ••• ......,... },... �'sai l M.D.
Address
Place of Burial (o emoval) vb,, •4 r— -e"----e---- .
(If body is to be temp lly held,fill In space later) /
Cemetery y :.!:. 4:..t.. /,.:.. _"' Cd Date of Burial I �.�3 1961..
(If body is to be temporarily held, fill in space later)
The 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 eke. the same for registration, have recorded it in my Local Record with the above stated Registered
Number,' on the basis thereof I 'HEREBY GRANT A PERMIT ,i
to .C.C�7Gr . -" ,,+ r:: -.4 i 1%.i�r ....,,/.l z:� ,r. �lrtz r � �� �.
(Na ----- (Address)
theU7 (..,4, to hold temporarily and..,.. the body.
(Underta r or perso Ravin`charge of corpse) (Inter,remove,or otherwise dispose of[state bow))
Dated / G�c32...5.3....19.A/... (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (.rbject to local
cemetery or other regulations), unless removal is by common currier, 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
_ v
Date = r
19
•
(Interment or •'Y."- /
(Name of Cemetery, Crematorium, etc.)
Secti / Lot No 6 Grave No.
/;72(
(Signed) .% /,kc�, 44;'
(Person in charge)
Address_
ee
Person in charge must return this Peerrm1t 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.