Keating, Leon Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or ThL Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Mfllage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No gis --5...._
, , Village
)ist. No�..�a.0 l County...w ...=.�^— or City
r (If city, a street addre e)
Jame of deceased... >�r. . , /r.a-r Veteran
~�'- 1 Sin 1 married widowed, _ cif Veteran, give name of Wu)
;ex Color...W or divorced (write the wrd Date of a c"' 19 4,2._
kge Years f Months . ..Days . Birthplace. .... TIrr-re )
.• A1
:ause of Death 170...:4.-‘---,
:ertificate was sigib ........... ...... M.D.
Address
'lace of Burial (or Removal).... . .. ... . .
If body is to be m orarll bel fill in ace later)
- Date of Burial.— "� 19f� ,._...
�emetery •
If body is to be temporarily held, 11 1n apace later)
I'hq Certificate of Death, ontaining 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,
have accepted the same for registration, have recorded it in my Local Record with the above ed Registered
gum , and n the basis thereof I HEREBY GRANT A PERMIT
3 Yame J dregs) --I he 2/rrx�.. �-r../� �: ) to hold temporarily and body.
(U ker or person acing charge of corpse) (Inter,rpmAye,or oth.riee dispose of(state how))
)ated � 19.. :? (Signed) ( c `-Qc ( �''
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert 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.
F!DORSE►E T OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of ( was 19
Interment or Cre ion)
41.
Mane o s�eter Crematorinn etc. - `
( 7r s )
Section <'< Lot No. ,�'
a7 I , Grave No.
(Signed) . C i A.'Uc! 41,104.<6
rson in charge)
Address Y3r/tjtld S
112e/t / /a).2
Person in charge oust 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.