Reynolds, George Form vs.air NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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.__..s.L..: f
i
Dist. No..:.? Z.County....Y .c..�x oriCiittye ' z� .4. .:�
�' (If city, give dress)
Name of deceased „r;.-.-1,4. .. .. j!�11(441-6 Veteran
—� , Sin e, married, widowed, % J// (If Yet •n give name of Wax)
Sex....�,r` ' Color.. or divorced (wnte the word)....A-!..A2�r.2n'-ejDate of 1e�th 2 hI �- Z19 - c---
Age ?-- Years/ Months Days Birthplace lr. .:.. .•.
Cause of Death .1�./.P . t--` .Days
7 in hpl :�-
Certificate was signed by ,. � .�il.Y'i �,_... ,- M.D.
Address �a �r ✓ =' (1� � ‘,._ ...
Place of Burial (9r Removal) f:- ?,1 e e� �.2?�
(If body is to be to o rily held,fill in spac�e ater) i
Cemetery....,/..,,-,`Y• :... •4: ....C. -.zg...., Date of Burial ....a�� 19
(If body is to be temporarily held, fil space later)
/
Ths Certificate of Death containing the above stated particulars, having been presente" to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num , on the bnai thy i HERE GRANT A PERMIT J�
/2-4_,
�ss / the body.
the . .�G. .... ..�ti:A4..'4- -/ to hold temporarily and.... Y•
(todertak r r person Navin charge of corpse) fluter r move,or erwise dia'ose of[state how))
Dated • :'G.2..... J..19. . (Signed) Q zA--e,, I,L,,..t•\,
• Local Registrar
This P 't is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'tate (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
`t.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of ✓ was e92 . 19 67, `—
(I aent or.
,-/d;',e.--2-.)--
(Name o Cemetery, Crematorium, etc.)
'(- ?:(::-,1=1::
l _i _
n
Section Lot No. Grave No.
(Signed) /./2-h %k_-: �72 (_, ",..-
rson in charge)
1,,,,d--
Address ; 0 k ,,-a
-_, w;'7,;74:7 - -2--2 ---).
Person in charge Heist 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.