Hoag, Leo Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W 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._ ...16"
Dist. No....?. :....t...Coun ... ✓ :.?:x:° r or Cityf" ,'
'• (If city. Btve st,r et address)
Name of deceased ' ` Veteran 24
• Single, married, wl wed, (If vet ive name of Wax)
Sex..7. .. ..Color v'" or divorced (wnte the word). ... / Date of Depth,. �' ��j 19..4z
elf//
Age ��....Year ......Months Days Birthplace....,:-'��—.�.Zr �. -`-� `'� ',! y
Cause of Death.�, .I~ ¢7 /�, , .-41. .-a;r� f
Certificate was signed by... '. 4.. M.D.
Address ✓�.e �t fliel' _ �Place of Bunal (or Removal ... ...,- ...�`:�� �� �.�. .... ... � L
(If body Is to be to arily
�' �et�, s ace later) � �
Cemetery �.. : �"' `2<° r...C '2 i Date of Ilona] G � /3 19 t,
(If body Is to be temporarily held 11 In space later)
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
Nu { on�th�er basis 1 HEREBY RANT A PERMIT j '
to niL�� �./ .".l.X.`.srg...r '"t:�ry /ls' -67"Gr ':. - -ci . n...t/ '
r /[
/,�_ tt�J Taw.),
�� (Address) //////
the 2'—' e 7" to hold temporarily and the body.
(Undertsifeo person Marina charge of corpse) gic,(...lt:ater,rem e,or otherwise disgosQ of[state bowl)
Dated `' ' /1...19... .... (Signed) �"�n�`.. a1 Registrar rJ ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the Slate (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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was(Interment
/3 is6
Interment or Cremat
(Name of emetery, Crematorium, etc.)
? RuLt/" c
Section / Lot No. J Grave No.
(Signed) " 1/ ao < 'Jgtt4)C . II //j_,
�5 (Per in ce)
Address 0 a, 6 O 0
-,16(
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 OF'F'RNSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.