Eaton, John •
Form Fs.s><. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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.
Village
Dist. No County..-2 or City
(If ty, give street address)
Name of deceased lY.... .. Veteran
Single, married, widowed, (If veteran, give name of War)
Sex .tot,�k Color.. ... . ...or divorced (wnte the word)...229(0!Yk.4.4:1 Date ofDeath --P- -2Y 19 62--
Age Years Months Days Birthplace ?Z.ti4c..r..�,".litcr-a
Cause of Death....... ,,..622.,: —.�/. -,-* .tsl/.... .,.
Certificate was signed by . ... �'' M.D.
Address eS./a. �.aiFn . .
Place of Burial (or Removal)...., �trxto... 1.66.r �7.:..X
(If body Is to be tempo9t11 y keld,n I7-.pace late
Cemetery .1.e.-i,-:x. ...... !:t.V. w' Date of Burial ,.i Ji 19.G.kr-
(If body L to be temporarily held,All 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
Number, and the basis thereof I REBY GRANT A PERMIT
to 2 7t !E �� 71. d ,21ir,� �; 4 i•
'-')
the � �a )�tiJ to hold temporarily and ,/ (Address)� the body.
(Undertaker or person having charge of corpse) (Inter,remove or heyvise dispose of [state howl)
Dated �,�!ly4 t' S 19..Ca& (Signed) '�. . ,,a4.0--
%!�� Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (enbject 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 SH:X1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH IN1TS OR CREMATIONS
ARE MADE
Date 19
(Interment or
( of Cemetery, Crematorium, etc.)
Section Lot No. — ) Grave No. J
(Signed)
� .
Person in charge)
Address (g--.1.-1.-/c3,4p���'l�C�—t[ ■['���/ A
Person in charge must return this Permit&d
the Registrar of his District within SEVEN (7) DAYS
frown 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.