Rowe, Irene Form TEL 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 Regi _ ._tered No r .
Village /j
Dist. Nd C11.(.1.C ( County..... . ‘j.-'h- or City 7� ,r... 2 7
(It city,give street ad�dd``��''a) 1
Name of deceased CO Veteran /v�
' , I Single, married, widowed, /`i I) (If v reran. ive name of war)
Sex Color W or divorced (write the word).(/" Date of D ),9 63
Age 6 6Years... ,Months. ... ..............Da s i _ e .. 0 ,�, 7
Cause of Death ,, t'�'�'t�a - -�!.. .4
y. ...... ........
M.D.
Certificate was signer%�� .. ... .. -�... ..
Address �.�j...... . .�/
Place of Burial (or Removal) ... -? ...(� �j �``��`�""",-,.(i
(If body Is to bette mporaril eld,,, 111� s ce I ter)
Cemetery A...#........ �c.C—�t Date of Burial / er 19..�?.:a
(If body Is to be temporarily held,till in space later) U
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 above stated Registered
Num on theme basis� th rf�I H�ER_E a GRANT A PERMIT ;-14 d /,
to v l�/t-��-A`
(N ,1. i—(Address) f
the to hold temporaril nd the body.
(U dertak or person h ring charge of corpse) j (Inter,remo ,or otbe dispose of[state howl)
Dated 19.k.- (Signed) s.1 1. .). . . ;rz,s!L
R
This Permit is su dent for the Removal (and Interment or Cremation) of a body to any part of the (*abject 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 INTERMENTS OR CREMATIONS
ARE MADE
Date of .wcasz44 `f 19 3
(Interment or
1(
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 11 ,
(Pe in charge)
Address 6 e e
Pougie
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.