South, Chester Form v&6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
__ 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- .b--
village zi
Dist. No..5-"/ County
(If
city, give str t address)
Name of deceased .. e.1--6--p- C.,/ \--- 47.---41-4 Veteran ) -
)
(4/ Single, married, widowed, ), If veteran, give name of War)
-),, "
Sex. '\ Color fif or divorced (wnte the word) 1/ a- Date of Des ,c.72---/.= 19‘ ?---
Age .5-g- Year Months Days ' Birthplace .6.4.. l-4.e e-- 7'
Cause of Death s.2-1. a---?-z-„,/,_.
Certificate was signed by i '. • '6.2:::: , (,-7,-',_ M.D.
Address z'.7 '-a' Y
Place of Burial (o emoval) -7---.42-‘/).9 -7,„--6./..-er-e---,-e--tz.- 22
(If body io to be temp ly held,fill in space later) ?
Cemetery ..),..4.-ads...C. /0Z.4i.....e47- C-4,---/--)'? •
,
Date of Burial C /
19
(If body is to be t porarily 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
Number, pinlin the basis th I REBY GRANT A PERMIT
to (,...):11,,,a.--, .,„2,., ,44'1,--1-"7 - -e-z-i - 10,...,. f
-
the -.//ki.„Ge17.--C- .7 to hold temporarily and.. --- (Address)
g.-:"-x--- the body.
(undertaker=having charge of corpse) , (Inter,L7,7,or otVrwise Ors, se of(state how])
Dated 19 ‘2— (Signed) J7-.....4.__Lu,‘..„
‘ ,.( (..-{...-/,
( 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 CREMATIONS
ARE MADE
Date o I %!nc was k" 19
(Interment or Cr
f / f
(Name of Cemetery, Crematorium, a .)
Section - 7 Lot No. �/ / Grave No,
(Si gned_____/2/ /C!`
(Person in charge)
Address/-,K>. 7/7_4< ,
Person in charge must return this Permit toy
the Registrar of his District within SEVEN (7) ,-D S
from above date. If no person is in charge, e
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"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.