Bennett, Harry _,. r. vs.di- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
st 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 CERTS6TE OF
DEATH, LEGIBLY WRITTEN DURABLE BLACK INK. T. „t,` Registered No.
Villa
Dist. No.a.S7COUflty...Z3. 1 (\40t* a or,Ci +
(If city, give atree s)
Name of deceased > Veteran •
... . ... ... ....
Of veteran, live name of War)
Single arned, widowed,
S .ColotLD r divorced (wnte the word) Date of Dena •• ••O�ti• .1 • -'
Age I ears. .l aak, •nths .D. a Birihplace.O• . •• •
Cause of Death_ .••
Certificate was s' ed . 111 /401 i`'... .• "1 / . \19 M.D.
Address
Place of Buria'LL'\\//or Removal) :. , .... - . ••
(If body Is to be tem)orarlly held,t}1 in'bace later) /
Cemetery �� .....�,,f../li..*. Date of :urial .... 19
(If body i 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 a• • stated Re istered
Number, and on the • .sis hereq HEREBY GRANT A PERMIT v. -
,` ,,',... r �.. • -
Ls' r
the '' ..•- to hold ten:poralpy and 0.. ..:. body.
(IInd er or reon paving cbarge.oi corpse) (Inter, remove, erwJ%e disooae of [state h .
Dated ,..�. 19.(Q,. (Signed) .° Registrar t\ 4itipe.,.� `°" \
LocalThis 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERIMEdTS OR CREATIONS
ARE MADE
Date o,ZI.,.'J r was 19
�( ^ (In te men c or
(Name of Cemetery, Crematorium, etc.)
Section Lot No. // 2---Grave No. tV
(Signed)
. ,,,/7/.24..00/-14". 4000Y.Z.--'/-e.--:—.
(Person I ch e)
AddressJfft .-:1)
�✓
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAY
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
WENT, 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 O1mNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.