Brewster, Guy Mr VS.ea. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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.__.._. .721
� �N) Village h/? f ,
Dist. No.�2U.J..County . or City
(If city, give street addre Y
4--Q-J- -€-`-L- 6---t- Veteran
Name of deceased 4 `
Single, married, widowed, (lf releraa, aloe name of Wu)
'�1.`,'- ( ,` 4 � ,`
Sex Color or divorced wnte the word) Date of Death.. ?1•A-a''' � � 19
Age Years Months Days Birthplace ,
Cause of Death f ' ` ---1"--1---1/2---1/2 -1,-;-,-;:,
Certificate was signed - M.D.
Address L 4 `::ui��,�l::
F,.1: '
?
Place of Burial (or Removal)..... '"-' `Q c..:.4: ../2„ n-�-�'"-. ,
(If body is to be temporarily held,fill in space Inter) v /
Cemetery .. ..c:::. ....:1' `�' Date of Burial � - "` 19
(If body is to be temporarily held,ell in space later)
Thq 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
Num on th bgs. thezrf I HEREBY GRANT A PERMIT V ���i . /79 i�
ams) „� (Address)
the ( �� � to hold temporarily and �'" the body.
(u 0 rtaker or person having charge of corpse) (Inter, remo ,or otherwise dispose of [state bow])
Dated � � e P--- 19 (Signed) '7...-"z`L.
l• al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stat. (.object to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
INDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o was 9
(Interment' or )
(1) 27/'
(Name of Ceme to , Crematorium, etc.)
Section Lot No,-/C Grave No.
(Signed)
Person it o ergo)
6
Address
Person in charge nus return this Permit 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.