Goaley, Rose Form VS.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ur 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 CERTI ICATE (V__
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Registered No.
Dist. No5..(�..c1.L.Coun ..... — -- or City � �^-7
(If city! ive street address)
Name of eased �---- • Veteran
Agle, married, widowed, t ti^ �fo if , give
rau ° wu)�j
Sex 7' Color or divorced (wnte the word) ... .... Date of Death...Nor,
19
Age Year ,,Months ,.,,,Days Birthplace
Cause of Death
Certificate was signed by 5 •.,:v r ,........... , /0i M.D.
Address ,3
Place of Burial (or Removal)....... .--1....P ..t?i-�-4,
(If bodyis to be ten_warily held,8l s e later j/ )
Cemetery y 0---- ' r ) . Date of Burial /1- — // 19
(If body le to be temporarily held,filV n apace 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 Re ord.,with the above stated Registered
7b .fIYGRANT A PERMIT y- Ax.
f7��-6 t a.me3 ' to holde mp/ t oraril and.... (eddra the body.
�i
(U dertaker or pertwp having charge q corpse) (Inter, remove or of e�)diaoose of state how))
Dated...: .. -- '- /Z11 19... V�. -- (Signed) ... . ca��
•�� ' al R rar �U
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to goy part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit ['trait (VS No. 62) is required.
i .
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Dai,e. of \ " 'Was ` C// iy
( nterment or Cremation)
(Name of Cemetery, Cr matorium, 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 th. 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.