Jenkins Jr., Harold 747r vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit tan 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
y
OF
KDEATH, LEGIBLY WR IN DURABLE BLACK IN Town Registered No.__..?
�] � Village
Dist. No..t" ��. :................ .:,�, or City
(If city, give r add se)_
c
—
Name of deceased.... O L o Aq f I ' J ,
Veteran •.�. .o�t;..._..r '
r (1,Q�an, give name of War))
Single, married, widowed, k
S . .. •..44-Col .. .a-or d'vorced (wnte the word) Date of Dea �► �. 19
Age 14--- Ye r ... onths .... .....Days Rthplace
Lvl
Cause of Death ...
cry
Certificate was siped b L... M.D.
Address �1�.. .. \.. . r
Place of B (or Removal). :. ..
(If body is to •. ••porarily held,ell in spa _ t y
Cemetery.... .. �. Date of Burial....,1..� 1..Zt 19. 2_
(If body is to •= temporarily held,fill in space later)
The Cert.•cate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin: to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I ve accepted the • r :stration, have recorded it in my Local Record wit th stated )�A gistered
N , , and on the a is th ' I HEREBY.GRANT A PERMIT
tom4: ,A_a 4.. (eddreoq I
the .. =" . .04) to hold tempos and �` he body.
(IIn ertaker or aring cha corpse) (Inter,remoy oorr th dispose of [state ho
Dated / 2 777 15 .. 'L (Signed) 1� , �^--&
LocThis Permit is sufficient for the Removal (and Interment oe C emotion) of� f y to any part of the State (iubjsct 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 of: was 'ti'1 t C�/ 19 Y r�—
(Interment or 'Cremation)
(ter/
(Name of Cemetery, Crematorium, etc.)
•
Section ✓� Lot No.- /� Grave No. .
(Signed) J,' 1�=►mot
(Person in charge)
Address 4/ <
Person in &Marge Host return this Permit to
the Registrar of his District within SEVEN CO 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.