Derby, Richard Form VS.6L 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._._..3"f Z
Village
Dist. No..�'6d,�..County...�� r or City �°�L_..: ��
/�" (If city, give street address)
Name of deceased a,. . !lS..l-�! Veteran -
Single, married, widowed, (If veteran. give name of War)
Sex y Color i/ or divorced (wnte the word). Date of Df..3th ... �—. ,<9C
Age r,..t) Yea y onths .....Days Birthplace &1 AfroK. t:r-..y....
Cause of Death f 1""'. '
Certificate was signed b . f- --- �1.7.:T?" : M.D.
Address ,/ L.c"t.> '
Place of Burial • Removal) 7-4f?:e27.. '. 7,
(If body is to be to_.. :rily held,fill in space later)
Cemetery +•.. i ,17.47<.uw"`d.�.7., Date of Burial ,� 7 19.t..-
(If body is to be temporarily held,fill in space later)
Thu 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num on the basis they! I HEREBY GRANT A PERMIT /
to ,..4 v im, 4;./ — ,!�.,� _ , � , . /;/
} ,_...-.-- (Address)
the � 7 �'°CfY to hold temporarily and.. .,4-4,,,,. the body.
ii(Undertak or neon ha ng charge of corpse) (Inter,remor or othe ose o disx [state how])
Dated �..?. ..�`...'t 19. (Signed) '� ''�'� `4��Jf
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 SEX[DN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of
(Ynterment o
/11-2
/_
(Name of Cmetery, Crematorium, etc.)
471441-ori-(.12-1-0 ,74'.
Section Lot No ✓) Grave No.
73
a
(Signed — Z< //
(Parse in charge)
Addres 1..-0 &-- MT
Person in charge mast return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person 1,s 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.