Morehouse, Baby Boy Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tor 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.__.Z
6 0 � Village
Dist. Nos 1 County....2./ as:cam or City ,�� - �'C''-,.:,
y� (If city, give street address)
Name of deceased � �,? �� L P--�— Veteran
C--) i �jJ�. marri€d, widowed, `/ (If vet an, give name of.War).
Sex f ' Color f / or divorced (wnte the word).. gf %Y746...Date of D .. ..2i......... .7 1/9./:
Age Yeam�,,,. ... ........... ...Months Days 7- Birthplace.. . .` .� .. .... ./e- % y ,.
Cause of Death K..1.../11 `:. ... lr.'-_t, -'fit /
Certificate was signed by ! .... - M.D.
Address �2.:-a - �
Place of Burial (or Removal) ,f..".7!1'�f.... .,r4 . . . - ' 7/7
(If body is to be tetp oraril ItjeDace later)
Cemetery '`'� 4-�' .. v:�. 4-QBurial z �- A
,�....... .... . . Date of x z- 19 .
(If body is to be temporarily d,fill in space later)
The Certificate of Death containing the above stated particulars, having been presen d 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 record it in my Local Record with the above stated Registered
Numbeqind the_basis the I HEREBY, RAN A PERMIT
(-t ) (Address)
theto �t:. — =r— to hold temporaril an . . �� the body.
(Linde ker or person having charge of corpse) (Inter,r move.or herwise 41snose of[state howl)
Dated 2,....Z--- 19..4�-S (Signed) (,'{�'yh
Local Registrar Cf
This rmit 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 SEXIDN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of AA-101--1-.---A-1.--," was■a,(5)0*-r‘ . .Z 1 19 6-3
(
Interment or Cr. on
(Nose of metery, Crematoria■, etc.)
sZi
Section Lot No. Grave o.
(Signed)
(person n charge) Z1g12.4441(.1‹..
Address a- '" - x 6 O 6, ( l
Person in charge oust 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.