Clark, Baby Boy Form vs.et NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFIICAATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered No—.... ._
, ) Village Dist. No,... 1.County....1 ---... or City �`-'-t'�-t1....f 4; � / 'f
� 7
(If city, Bice street address)
Name of deceased ... �R'�„�e)-'',"-' �.. Veteran
j n I Single, married, widowed, '�;n D g , (If veteran. give name of War)
Sex ' J&...Color ` or divorced (write the word).. "‹rc., tit Date of Death —� .19.
A e Years Months Das Birthplace .- ,�. ..,4 r./,i.7
Cause of Death. . . ..
Certificate was signed b .... .� M.D.
Address �E' C.i��"'L 1....,,1�f/ '�t �.vc,+ `�?
Place of Burial (or Removal).... ..w�� t/...:C.R-W � .�1�. . aQ tc2 dr
(If body is to 1 e-teys porarfly held,�fy In space later) -
Cemetery _.J .. :u Ll..rs.-�^- . . Date of Eurial 19
(If body is to be temporarily held,fill 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 on„ the ba ' thereof I HEREBY GRANT A PERMIT ( � ^^ i� ig,j4 ,1-1
to tL� �i itL,.....)... ... -e. --,AL. . CL_
Cl� d �, t ) �} (Address) body.
'�YL l `'� - �' �' to hold temporaril and v�-lS�;`" the
(U dertaker or gprson Raving charge of corpse) (Inter, remove,or of se dlsno,se of[state how])
Dated " :{:t. 2- 19.4..,? (Signed).....5.. .... ,.-..-,i 'tt__ ; ,..d .arse' ..,
' al esistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (.abject 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 CREMATIONS
ARE MADE
,
•
Date of.'"7 was' 19 ' 2
( nterment or
Cat ���z�• _./CfCl� t.�- /
(Name of Cemetery, Crematorium, etc.)
Section Lot No// i Grave No.
(Signed) 4e . ` ..- /2_
/
(Person in charge) �S
Address
Person in charge must return this Pit 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 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.