Sheffield, Samuel Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. = :,
..-tIlage
Dist. N ... .dl.County... C or City `�(If elty4 )<--7.c....----7-6
street address) �
Name of deceased -- --7---i--4,..(4•^Ca../ ••
Veteran
`,J Single, married, widowed, �,'/ , / ((f veteran. give name of War)
Sex _"1-14 .Color or divorced (wnte the word) (A/ ..rN-e�' Date of Death l i9•l�
A e Years Months Days Birthplace :•
g Y
Cause of Death .,--e---g i.1-r' ... -�..z..F,.....rr,---
. 4c.rsrl..�
Certificate was signed b3' ..2 p -� M.D.
Address = I.CP 4G-�- --�Y� /�
Place of Burial (or Removal) Z . . �..� `-'' �'- ^- "
(If body is to be temp. ly held,fill ins c later) 7::
Cemetery �—�-.� - ' Date of Burial �,,�-�-�'�' a`�- a 19..r:.
(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 Recor with the above stated Registered
Number, and on the ba is th EBY GRANT A PERMIT
to _']`�' 1 (eddre
the (/ •,. ,, to hold temporarily and... - 4c.511:
dy.
(Undertaker or pe n having charge of corpse) (Inter,re ore,or oerwise dlsoose of [state how])
^
Dated.........1'" ./ K 19 �'�--- (Signed) �.9..i�::..:(... tij '-i)-i ..----tom.
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
,_,...,-7/
Date o L C% 19 (� ?-
(Interment o -Sion)
'/:-27//. '-'-,=;) //
(Name of Cemeterys Crematoriums etc.)
V Section Lot No. Grave No.
j
3 I' v
(Signed) ',,-'��L���C �_ � C
� l -�2 t� L
(Person in charge)
•
Address l /� Cam' l- `-
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 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.