Daniels, Edward Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 fI?•._. _
Village
Dist. Not.P6 ....Co ty..._. . .. . ..• L ..r amity
• (If city, give st t address)
Na e of d eased Veteran L7L—e)
(If veteFan give name of Was)
Single, married, widowed, � �
S . olor. .... . ...or divorced (wnte the word . . . .. .. . Date Death
�/ r �G
Age.... .........Y rs Mo the Da 3i plac �'
Cause of Death .0 ' r '
Certificate was sign by.. .. M.D.
Address .
Place of Burial (or Removal)...
(If body la todAnteppor eld,MI in p er) i 19
-� y� ..5
Cemetery. 2:�`G.!'�4-��.1. •• • .. .. Date of Burial •�.../...�J..
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated pa iculars, 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 ord with the above stated Registered
Nu ' , and on a • thereof I HEREBY GRANT A PERMIT/ 4--74--- -Arra 4..
thi to hold temporarily and .. F f .-'' e body.
dertaker or rso caving charye33�oo�orpse) I(Inter,remove,o Mimeo of[state
Dated . .. . ..../.'.X 19(O..i?' (Signed) ) • a... . .. • • .....if e7- •
• ermit is sufficient for the Removal (and Interment or Cremation) of a body ir any part of the Slate (eobje to loco.
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 iL wa‘_" 19
(Interment or+Crems
(Name of Cemetery, Crematorium, etc.)
Section Lot No. --- Grave No.
(Signed)
(Person in charge)
Address
Person in charge must 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.