Cole, Loren vorm vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
__ 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.__.._.......K>._.
/�jj Village
Dist. Na:�.lpir. ....County... d ``\. or City
(si If etty, give street a ressk J
Name of eceased ‘" '°� `+- •. Veteran 1 ' 0
Single, married, wido ed, '.• (If veteran. give name of War)Sex . , .. ..Color `' or divorced (write the word)..... Date of .I 19. .
Age L e. ygrs nths... .. .. ays r Birth Q..
Cause of Death . .. et.
Certificate was signed b r. M.D.
Address . .... . ...Place of Burial (or Removal). 21,„, I) ! L..J
(If body Is to be te�porarily held,fill In spice4ater)
Cemetery y: .,4.~ u ts-4 1.�'. ........ Date of Burial 19.
(If body is to be-temporarily held,fill In space later)
Tht 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
'un07 on the basis . I HER;EBY GRANT A PERMIT - �
i0 .ti.... ( .. ... - 4
(Name)
the ,. to hold temporarily and ...� .t e body.
'ndertaker or person having cbarg of corpse)
(Inter,remove,orsrise s9 se of[state L *)
Dated .f-........ 19.(,CL (Signed) .. ...
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any past 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 SI XIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE 7. -at.ji
, '
Date of 71 �.. /7
was <c. .U-e� 19 C�?i`
(Interment'3T-1�aarri
, (77
/1z <c �'",�Zc
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 72eflz ` `'' gel c"- orl i `-
-;?;25'
(parson in charge)
Address / O 2t %' 14-f;t =t--- � ! _.
L
-1.� 74(' .
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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.