Fish, Joseph Form VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
M. This Permit cams be signed only by the Local Registrar (Deputy or aubregistrar) 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.__.:_5.�.. ::__....._-
f Village �/��� ?t &-
Dist. No f?; County..... .tr: :.'�Ir� or City '� '`�
(If city, give street address)
r —�` L Veteran G.-' ‘''�
Name of deceased , j�l. "
'l Single, married, widowed, �,'>> (If veteran, sire name of w.�>
Sex 1 i'i Color...l ✓ or divorced (wnte the word) "6 Date of De �� �4- 'y4� 19<-' -S
Age 7. Year, Months Days Birthplace }'`�, ���
Cause of Death C. :... .:, �. 7t:C::: '�--t `n
Certificate was si ecl_byl Cr- .4--- ` ' -{4 M.D.,9%-, ,,,
Address /�- — "��- �t �!.t �,�.: cti-C/ A,
Place of Burial (or Removal) �t� ��ca.E...... .t .rti :.......
(If body is to be temporarily held,fill in later) \
' ' `,' ) u,'• 4 Date of Burial - "-;{“, 19
Cemetery r ..::tis'.4.
(If body le to be temporarily held/ell 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbera�ngddon the b is thereoff..I HEREBY GRANT A PERMIT (. �`�
to . ,c,4 t.// ()`v.4, ..( -e i ' ` --t1"%............ .t' ; ' - .1
��,tLc'i% cl L ( res
the to hold temporaril and 4.::. .ie,., , the body.
(Undeier,or person having charge of corpse) (Inter,re ye,or 6tXrise disco a of[state how])
Dated g �:. '"' 19 .. . (Signed) 4-
f/ Local 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was a • L 19 6--3
(Interment or Cremation)
(Name oP emetery, Crematorium, etc.)
Cis-C� .4.. J �
Section Lot No. Grave • Al•
'�7/e- adze.e.
(Signed) a
(Per in charge)
Address e Q- 'a°X- 4 o o k )6-1-L. , .
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.