Searman, Ida Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. Tow., Registered No.,2 6
�'r.,? - Village
LaretT4 Dist. No. . i� County.. �i�
`J (If city. give str t address)
Name of deceased , . # i cy
Veteran , -
Single, married, widowed, -L.,
(i( veteran, give name of War)
Sex olor..% or divorced (write the word) �k (� Date of Dea ^..Z 19>% Z
age .Years Month .. ays Birthplace ,.....
:ause of Death ..Ii.'! . . . .
:ertificate was signed by ..y'�.... .. 'f. .. :..,. . M.D.
Address Jl ,ram
Place of Burial (or Removal) «: :..,
;If body Is to be temporarily he ,fil a later)
Cemetery ld Date of Burial 154a Z
;If body L to be temporarily held,fill in space later)
fhn Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
iation, 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, and on ee C EBY GRANT A PERMIT
o
���� ,� �a�j(
he s� `�I Ll .._..to hold temporarily and ea Ad the body.
( maker or person having charge of corpse) r otherwise dispose of[state howl)
Dated APR Lir:1962 19 (Signed)
Local rgtstrss
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
:emetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX'lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEEMENTS OR CREMATIONS
ARE MADE
Date of �.�`i- r y was 19 1. -- •
(Interment or Cremation)
•
(Naas of Came te1y, Crenatorium, etc.)
Section Lot No. Grave No.
(Signed) f" ;.._r-•._; � �f t�"''
(Person in c s1gn)
Address 1 rA cV'(4.4. ''-'`
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.