Peters, Grace Form vs.sL 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 Town Registered No._.,. _.�?7_.....__
'f"��'ir � Village ct,.egc�
Dist. No.. �aA.j..County... . ..!."...». . ...... or City
(It city, give treet address)
Name of deceased.... Veteran ��"v •
Single, married, widowed, (If vetiiiip, give name of War)
Sex....ir i Color..,ef or divorced (write the word)` £ Date of D ....AIF `.../ 19..C..Z
Age aYear Months..............»»...D ys Birthplace.... �' .
Cause of Death
Certificate was signed by ... q j ....... . M.D.
Address p /...
Place of Burial (or Removal).... e—�—> ..
fr-
(If body is to be temporari] e I pace ater) / l
Cemetery C.a - Date of Burial ,yl 19.E Z--
(If body is to be temporarily h d,fill in space later) �/
Thn 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 accep ed the same for re .stration, have recorded it in my Local Record with the above stated Registered
Num on the basiseo EREBY GNT A PERMIT
a?v
(Address)
the to hold temporarily and the body.
(Und er or person having charge.of corpse) (Inter,remov or oth se di nose of(state how])
Dated ��1. ....1 19 2--- (Signed) r,r:� :s . .r� 'c-r
rr// Ill Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (*abject 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 SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
Date of was )17 19 6 �
(Interment or *a.et+en
5)( .
(Name of Cemetery, Cremator um, etc.)
Section Lot No. Grave No.
(Signed) ,, �////////{AA/,,tL
(Pe aon in'charge�leiZt6LAr—.
Address Le.ge,t,f4 �,&e4
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.