Mickel, Eileen -,r r�: VS.Ra- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr 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 CERT14IC.f. OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK IN Town Registered No. .- ._
0,-" Village
Dist. No Coun Ie! or Ciy
(If city, give street'. tees)
Nam f d ased ....1 t-- F. ) ....L. P/1 lc I.(E" Veteran
tatioSriniilveo,g married, widowed, (lf velersn give name of War)",
..19b1.Sex i olorced (wnte the word Date of th.�.. ,,.. A.
Age ....ir.rs Month ........ .Da place r-• .'•• .
•
Cause of Death__ .... - .. ,4 . . .. . `�. . ., ..—` ...
lliP
Certificate was si ed b � & �,... ,.•• M.D.
, iy •• i��
Address f Place of Burial (or Removal) lir �. • ... - A .
,08
(If body 1s to be te➢oporarily hel 11 In space 19
Cemetery....•. („).j+• ••• riii
Date of Burial ,;�
(If body is to be temporarr y 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 accept • the same for registration, have recorded it in my Local Record with the above stated Registered
Nu , and, r1 basis. - •f I HEREBY GRANT A PERMIT
ss
the to hold temporarily and the body.
(Undertaker or,,��ee having charge of corpse) (Inter,remove a etherwlse dispose of [state bow])
Dated ' —' �i 19 (Signed) r` 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 CITATIONS
ARE MADE
Date o 19 6
( uterment o remati
Name of Cemete rematorium, etc.
Section Lot No. ( i f/ Grave No.
(Signed)
(Person in c a
Zi
Address „
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) YS
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 OletchNSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.