Cosgrove, Rose Form VS C. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Cr 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
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._"...,i`..� ._
�r � Village
Dist. No..�1 Llr.�..County........ " or City 7-0_1 -'-,
s (If city, give street address)
\Tame of deceased ` j i.� : `� Veteran �`—�'
/� %, Single, married, widowed, (If veter give none.of.War)
;ex....J Color... or divorced (write the word ..... ..•.• '-'iv Date of De th '�!.L% .,•e3•1.9,a ?---
kge ,Zz-- Year,, Months Days. . Birthplace I • y....23..4- •
:ause of Death ( _,rT a�-'z., e (-71
certificate was signed by �:. M.D.
Address ,,;_ x..L ).? l
`'
Place of Burial (or Removal) 2-)1%)- ~�-x. ,. ,/ �,..,. rl
If body Is to be temp arily held,fill is ace later) � j i�
Cemetery l .F:r.--,.:t.. ,.r..c.�t- (,,,u Date of Burial ,,4e rr 4r J,b 19.‘
If body is to be temporarily held,fill in space later)
Ile Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
f have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Vumber ptr tke basis thereof I HEREBY GRANT A PERMIT
/ ( ) (Address)
he i-'-(-{,'' to hold temporarily and.... -'Z C-7 the body.
(Undertaker or person having charge of corpse) (Inter,remove,or otherwi disooae of state howl)
Dated ,,�.r�lf''^-�-- 19 (Signed) :.-e..,...: ..a !L �.'r't
` Re�iatrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
:emetery 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 INTERMEDiTS OR CREMATIONS
ARE MADE
Date o —7 L '-.Yric_-/ was
(Interment or
(Name of Cemetery, Crematorium,
Section Lot No.///1/ 1- Grave No.CI
r
(Signed)
(Person in rse)
Address
Person in ch must return this Per$' to--
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 TRREE
(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.