Van Marder, Ennicsa Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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.
Registered No.__ .....��....__
Dist. No57-e/ County d ----¢- or City e •a-ry,_.. „4,
7� (If city, give street address)
-
Name of deceased. ,.s.,.e..j -. -'-- 7.4f.A.e Veteran
/%„ It-) Single, married, widowed, (If . eran, give name of War)�
Sex `�. Coloror divorced (wnte the word)�l� ....... J Date of -e , ... ....•...••••19. ....
Age �� Ye Month ....... a - irthplad.:.., .. ...... ..�..��.:.
Cause of Death•.
Certificate was signed by. ... _ ,rs M.D.
Address.. .... < �.,&i.e!� i .. ,. :,
Place of Burial (or Removal) .—'YL— ..rr.
(If body is to be to rarily held, 81I In apace later
Cemetery --e.::x-,....e.„,- -- '� Date of Burial cV-- d 19.4.)---
(If body is to be temporarily held, All 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 accepted the same for registration, have recorded it in my LocalRecord with the above ttedRegistered
Num , and o thebasis th .I HEREBY GRANT A PERMIT
.7
(Address)
the to hold temporaril and. t•........., _ dy.
(U.' take r707Avnig charge corpse) (Inter, move,br" erwiae disoose of [state bow])
, 1
Dated...4 .... 19 ..P_ (Signed) ... . `-)1...r...�j
trot Registrar 1
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (subject 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 SEX'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o was �"'` 19
ntersent or Cremation)
•
C " sae of Cemetery, Crematorium, etc.)
Section /��� Lot No'OS Grave No. /r
(Signed) f �- -� -� `�
(Person in charge)
Address C
Person in charge mist return this Permit to
the Registrar of his District within SEVEN (?) 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.