Derway Sr., Joseph Form OS.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Fir 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. _ - ..:J
Dist. No County °)c`-t'.....:.....:..:,.,. or City Z
(It city, give street address)
L
Name of deceased ;k .�?: sz., - Veteran
-%'i Single, married, widowed, (lf vet n. give name of War)
Sex .Color L' or divorced (write the word) Date of p i .-"Co-.. •2? 19 -',,I
Age Years _ Munths -- Days ---- Bi �? n
Cause of Death
.T�;.
�. - '`Certificate was signed by. �i K.-�-- �- ...�-��:� �- ``/ .... `� _ ---- - -- _ M.D.
Address G=fir sZ...
Place of Burial or Removal /Ul%rl..?!7....!"�.... ... . . ...:f:� r1.,
(If body is to be to rarilr�--the , yin space later) ,y /Cemetery
.. ....64. ..flru�.1K-ac4..c,.. -Y) Date of Burial / 19.. �'
(If body i to be temporarily d,fill in apace later)
The Certificate of Den 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 acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the asis t )HEREBY GF ►NT A PERMIT 6.....cit... -
to ,,„--rci y cy,,,,,ri l Nae) �J (Address)
the x e` . ." m to hold temporarily ands-- �'7� the body.
(ppnefiertaker or pe appaving ebargy orpae) (In r,re or or otherwi dispose if estate how )
Dated..4.4 1 .....,�' 191:7 (Signed) LA--) `"
•• al A
This Permis sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( bject to local
cemetery or other regulations),unless removal is by common carrier, in which cane a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SKXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMEdTS OR CREMATIONS
ARE MADE
Date of, QJt.rr ,,,f was ( . / 19 �o—3
(Interment or Cremation) �J
fill
4-4L"---,----1.--4.---0 •
(Na of Ceme ry, Crematorium, etc.)
dLQ/�lA/� ' yv7 if. ar/1 r
,4l14U d ` r'
Section d2 Lot No. Grave No. • l
(Signed) 1 ' Ln
in charge)
Address f
O 4 6 0
L, ,
Person in charge must return thi ennit 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.