Dolan Sr., George Form FEL aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
`i 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 QF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._2.0_6.. -
Dist. No6- .�..� County ")` � Village "-A----or City �' "J s;lcz 'o
Q (If etty, give street add e,)
Name of deceased i' kie '@--�'-" , Veteran '
�� 9 Sin le, married, W1dOWed, �, ,',� (J (lf veteran. givve name of War)
Sex ! Color �� ' or divorced (wnte the word) �����" `"S Date of atll 49'-'�1....7.6, 19.�..z-
Age `� Ye rs Months.. .... »...Da lac ..: .a nr �f� ...°�1..
Cause of Death -AAA- � ..) „`k-6i.c..•••• -�> 1-t.it..�E�"Pie-mtct�-
Certificate was sign by..„e: �L.trG - M.D.
... ... G?�-
3_21
Address.....h: ...
Place of Burial (or Removal)....
(If body is to be tempprarily held,411 in space later
Cemetery....' �.:i: ....1,1-S-e-..-�-. 4-LtiA-,\., . Date of Burial ` -i- ( 7 19.
(If body le to be temporarily held,fill in apace 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 on the basis thereof I HEREBY GRANT A PERMIT ,
to a ..A... K�`:r►ti!Y.„ .. A.-cc'..,:.. 'ice 2ccd
( m ^4 the body.
the ' to hold temporarily and -� Y
(Undertaker or pe n having charge of corpse) (Inter,rem ve,or othe se disTwee of[state how))
Dated ,Li 19.E <- (Signed) Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Slate (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 CRE4fATIONS
ARE MADE
--2*
Date of) LJ was - , f: Z,y 19 (y'
(Interment or_,Cresmtrion)
)
/ )77- /77.
Fame of Cemetery, Crematorium, etc!)
Section Lot No. 1 Grave No. _
r yc�
(Signed) ��i'ton ..i C G�
(Pe s in charge)
Address ' �, . `✓� � . '
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOP. or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"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.