Manion, Agnes Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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..? ..414'
ty Village : / '
Dist. I County or City '��
(If city, give street address)
Name of deceasedei —',- Veteran iti
�y (Ai Single, married, widowed, (If veteran. give name of War)
Sex '1 Color or divorced (wnte the word).. -A-A Date of Death.... f - / y 19
Age - Years Mo the Days Birthplace t. -, ••i•••• • •••7••
Cause of Death G 1 ; /1. - - -- -
Certificate was signed by Pitt, +2- M.D.
Address •
Place of Burial (or Removal) Z `- 4-(1 Lvtf* .✓ ...,•• ..
(If body le to be to g{arily held,fill in space later)
Cemetery ,'V t' CZ -e i. . c.4 Date of Burial �' - / 7 19.Z..Z_
(If body le to be temporarily held,11 I 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num and on the basil ,the I HEREBY NT A PERMIT
7
1 -111 °--(31'(Na" � -Q.-" dress)
the ��"1' to hold temporarily and .'./.., the body.
(Undertaker or person having charge of corpse) (Inter, remove,or oth7ise dispose of(state howl)
Dated ,1 ,,<.<,x ,,.. .,r: .7 i9.la.. — (Signed) --
\.. alit l..t 1- -'� �'
ig�
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Mate (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORarmrlV•1' OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in charge)
Address
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.