Mesmick, Louis Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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._.c2-_�.7
;. . Village
Dist. No.... ... ' r County..... » !z.7 or City •2--- Q
(If etty, give str address)
Name of deceased ` z - mac. '2'y c:rar l-E<- Veteran -c.
T, Single, married, widowed, J' (If v°"a. give"lame of War)
Sex..... .." Color ,` or divorced (write the word). 2 4 7 V 1-1 Date of D th e-e-. 6..19 6
dr
Age . Ye r onus.. Days Birthplace - � *
Cause of Death i,,4i t :ca.— ...cf ... C.
Certificate was signed . . . . : :t, M.D.
Address .. ... AZ, ,Place of Burial or Removal) . .. C-Ili
p .
(If body is to be to orarily hel in Are later)
Cemetery . ., +..... s Date of Burial .�v 'y 19e
(If body is to be temporarily heldd,fill space later) '—/
Tho 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 R cord with the above stated Registered
Number,4451 on the basis,,thereof L EREBYGRANT A PERMIT
to cn°1-4=- G. ,.�t:YL...t `u- -- �C .
(1Iyip) (Address)
the 1 Z- Lf-- to hold temporarily andk .---, the body.
(Underta e or pe havi g charg,,of corpse) (Inter,rem e,or otIvisetr se of is s how])
Dated r 19€;-I (Signed) 1 '�f VI
del Registrar
This 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 SEX IVN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of App-v3! wasi° ? 19 41
(Interment or Cremation)
tk
(Name of Ce tery, Crematorium, etc ) (\‘j
Section Lot No. Grave No.
(Signed) C).4•45-1L
(Person in charge)
Address 1 L M ) _1 5 "` ,
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 acro§S. face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN Tom`" " a
(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.