Jeckel, Charles Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
a r 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 (F:
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. vZge_ Registered No......3.__..7 5
Dist. No 6 v` County ( ' i^-l`-Q-v-- or City . 46 .
of city. vr� `�
e street address)
Name of decease ..°-• 2cP .
iiVeteran
1 Single, marri , widowed, (If veteran, give name of War)
Sex olor IA./ or divorced (wnte the word( Date of Death....g". - a 7 .19 Gam.-.
Age .0- Year Month Dai. Birthglace:.. ...s .•• ••••
Cause of Death 4 '
Certificate was signed b M.D.
Address ......,- .L /1 J........ t
Place of Burial (or Removal)
(If body Is to be tempora held,fill in sp 1 er) _ /
Cemete �- -�- '��'e'�2" Date of Burl 3 d 19..1�.5 i
(If body la 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 regist rat' n, have recorded it in my Local Recor wi the above stated a istered
Num on th basis tt; ; f IREBY GRANT A PERMIT L
to a' -Qr . ... ... ..... (A dress) �
the .••. . t� temporarily and t bod .
(Unraker or rso ng charge firm) (Inter,remov ,or othe se of(Hono state how))
Dated ' .... 19... (Signed) /v\•
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (mbjeet 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 'L- was 19 t° 2---
(In termen t Cremeti
(Name-of Cemetery, Crematorium, etc.) - y
Section Lot No.,3 FJ Grave No.
(Sued)0 �y,` ` - _
(Person in charge)
Address /' 6 . 4.- _Ai PLOT,
2/-
Person in charge Heist return this Permit to2'
r
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 OYFENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.