Eddy, Harris Form vs.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
L!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..�0• VY_.....__
\\ Village
Dist. No.. ..:rja.4County...a.t..? .:. ... or City
(If city, give street address)
Name of deceased \C" )... Veteran
Q .. _ Single, married, widowed, (If veletas, give name of Wax)
Sex i r.Colo t....or divorced (wnte the word) -.a:1 ,k- Date of Death :.L..1..3.. .....19..t..
Age `) Y__ars... Months.) Days Birthplace Q-C4a....r,&,z. ,\ r,%i/ ck".,.
Cause of Death \....+-��-'-'--a,. ....:\... =..1x:r,�„ci- -4 c.....a..`.&:...0 .,
Certificate was signed by ____ At..S J !Z.... �--� ..... x- ,,_ M.D._
Address \ Q .. \-i.ts. i.! .... s.. ...."1...... I
Place of Burial (or Removal) \ .,. � "C,. ..... !-�,Rg
(If body 1s to be temporarily held,fill in space 1a er)
Cemeter
y .'cl,.rZ-'-","-% at.40,, Date of Burial ..:.�.$....\ '-;--- 194,2,3
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to e, 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, pd on the basis hereof I HEREBY GRANT A PERMIT
to :.c :..1s..ra k. ) ..1,-r:...r r.-m.. ....... .. ...
ame _ Address)
the to h d temporarily and <,.. the body.
(Undertaker or person having charts of corpse) (Int , move,or a se diso s of[state bow])
Dated \. ....19 .,S (Signed) :�>,.x � a� ..: .. . .
Local Registrar
This Permit i sufficient for the Removal (and Interment or Cremation) of a body to any part of this_ (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 2) is required.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
c
Date 191"---�
(Interment or,
r
•.7 •
(1)C-----t___.._*___,
(Name of Cemetery, Crematorium, etcr.�
e.,
Section trot No. Grave No.
1 /�
(Signed) �2/ `-, �. .?- "1; L
(Person)in chargee))
.42
Address. 6)0C:c L J i'[/ ---- ..�1.`�--
.......„..e.a., , , ,
Person in ch ge must return this Perini
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.