Rhone, Mary Form VS an. 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.__.._....(r'....
f Village
Dist. No`) 6 c'r County t1~,_ r--'-� or City %�' L"� j ��-�
1
• ,----- (If city, give street address)
Name of deceased /' ,( e--r ---`� -2- `-r-I' t t-0--r"k`�` Veteran
ax
Single, married, widowed, (If ♦e a*=a. give name of W )
Sex . ,Color -- t. or divorced (wnte the word)_.� .. ,1C Date of Death _ 76 19 -)
Age Years. • Months Days Biythplace
Cause of Death ._.t. =--sue •• 11 t—r`
Certificate was signed by..... C' .M.D.
Address -'-- - -e
Place of Burial (or Removal) .- 2-, t r.�: c-+..r1..
(If body le to be temporarily lie*fill in apage/later) 1,
Cemetery L _--�-- "-&---C.- ,..) Date of-Burial } ; 19.. -
(If body is to be temporarily held,fill is apace 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 Re istered
Number, and on the basis t HEREBY GRANT A PERMIT ( %"'`.-y` . ��'�'
to ;� .`.�... � • ,ra`,- '"'
` / ) --fie)/' , ,�(Addrese)
the //,n.; "� —f to hold temporarily and tom- �(-r . the body.
(Undertaker or I a having charge of corpse) (Inter,remove,or tberwie�.e enoee of[state how])
Dated..., ` ! 19 - (Signed) ir1).a .. .<:�k 4 u�.
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any Tient 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 C TIONS
ARE AAE
Date of i� I was cL , 19
(Irate rat Mr C mats )
4-2
lXtL
(Na
me of CemeteryY Crematorium, etc.)
Section - Lot No. Grave No.
(Signed) / .i
_ .. (Person_,,,P. charge)
FAdCIreSS
Person in charge must return this Permit
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.