Perkett, Frank Form vs.st. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI ATERF.
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town gts eyed No—_ ,
5. O Village Afix..4.4...,kJDist. No- 1-County..._. ..... Fe'L or City }¢
(If city, give street addles V
tf#
Name of deceased...... . .. Veteran
� pp � Single, married, widowed, rr ,, `` (If veteran, give name of War)
4
Sex �/..Color....L.Y or divorced (write the word).W Date of Death... •6 t-
Age 2 ) Y�e�as onths ays Birthplace 1. .. r •••
Cause of Death V. .A Certificate was sign by Q M.D.
Address n
Place of Burial (or Removal) ,, '.`xt.. .. ye7 ... 7.....
(If body 1s to l e to pporarilly held,fill in space later) �—• - r 6 �_
.t ..Cemetery... .J..:c.,:ii..A.....Li4-�' ,--C Date of Burial V 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
to
, on ate baste' t�ef I H�� GRANT A PERMIT - ���„ `� 4/
the � ." to hold temporarily and the body.
(Tin taker or person haying charge of corpse) (Inter,remo e,or othe ise dispose of[state how])
Dated � 19.‘,. .--- (Signed) •' �
itegistrar
This Permit is su cient for the Removal (and Interment or Cremation) of a body toahy part of the State (eubject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORaMEJT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of • was`' e1
• (Interment or C i n)
+/ (Name of Cemetery, Crematorium, ate.)
Section G' Lot No._& rave No.
n
(Signed) ��!>z 1Z - Oft7-et-,2Z '
(Person in charge)
Address tl��(. _€
Person in charge mist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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.