Swears, Florence form vs.st. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
(illage, 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.._._. ..._ ._
Village
)ist. No..,.).. .. .. County...-.Lt.1. ;-:.1L.C. 14.L. or City r�i,,1 y--
(If city, give street addres
Jame of deceased 7 ' Veteran
�) yn Single, married, widowed, (If ye Bran. give name of War).
>ex.2./.4 2..Color..1." ^ or divorced (wnte the word) Date of Di l 19'��j—'
age Years onths. ............Da s Birthplace...../.V..-K:*�r!:?4.. .. .4 '271
:ause of Death . ..
:ertificate was signed by - s :, M.D.
Address ) ��,. /2j4 / t?lace of Burial (or Removal) t
If body is to be!e9porally held Myra space igte ) /1)//
-emetery z--) A . .i..i�.4..oa.. % "v�.� bate of Burial .--� 19 6 �____
If body is to be temporarily held, II in space later)
Che Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
ration, 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 stated Registered
Vumber, and on thesis th f I HEREBY GRANT A PERMIT / f t--,:cx____e4 42
o :.i.j:1,,t G9''a'� -- /�)t rC�ll edaress)
he �'' '�f"" ""11 ii--�`_' to hold temporarily and --- the c ody.
(IIn rtaker or person having charge of corpse) J (inter,r, epiore,or otb .e dispose of[state bow))
)ated "'�-- i 19..6..._ (Signed) L .-- -�� X _
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body any part of the State (*abject to local
emetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of _ was.
(Interment1://Z 14-
ori?
o._
Pane of Cenetery, Crematorium etc.)
Section Lot No. Grave No.
(Signed)
(Person in charge)
•
Address 1(+ C, ezz.
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.