Stark, Roger -ot-on vs-ai- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ter 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._
Village
Dist. No.1.4:S.4...County..._ 61-, or City
(,Th (If city, give street ad�te�s)
Name of deceased ` �� t Veteran I'�V 0
�, A Single, married, widowed, (If veteran. give name of War)
Sex I mo-k' Color..A) -'7 or divorced (wnte the word) 4 A'1'PDate of Death i ~ / 19
Age Years Months Days Birthplace 7"'G -. '9;
Cause of Death .PY..Y.I. z�-4-1 ID`4'0_'
Certificate was signed by , '' M.D.r=..4`n'(-ate`
Address - �, .�
Place of Burial (or Removal)
(If body is to be temporarily held, till in space later)
Cemetery J.... :i6..c- i. -sue,..o ,,,"- . Date of Burial / 19
(If body is to be temporarily held,fill 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�j
Number, and on the basis there,Qf I HEREBY GRANT A PERMIT f� '� j ,� ` '7
C�<
to .4t---car — f
( p address)
the 6�--� �_ to hold temporarily and the body.
(Undertaker or person having charge of corpse) (Inter, remover or of se disoose of(state how])
Dated LA / 41 19 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMMATIONS
ARE MADE
Date was 4.5�19 4"
(i6 Rt or Cremation
'' '--7
9j;"-"---
.
(Nmme of temetery, Crematorium, etc )
“=-'' .,,S11 .-a'`lam
Section Lot No. Grave No/()
4t7-
,
/�
(Signed) ! C ,// '
f
(Person in Charge)
Address
Person in arge waist turn this Perta / ,7,
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.