Curtin, Walter Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit cams 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 CERTIF AT F
DEATH, LEGIBLY WRfTTEi( IN DURABLE BLACK INK. Town Registered No '.=..../''
Village
Dist. No � County...`C� .2�-v .� or City D.
>6 G ea/c2-��
J .______ ' (If e'ty1ve street address)
Name of deceased C / l Veteran
/ Single, married, widowed, / a (If eler n, give name of war)
Sex l /Color../v or divorced (wnte the word)`aY'`` � Date of Death l `-✓ 7 196
Age Years ,...Months. DaysBirth� ,C �... .._ lace ;�,
Cause of Death (:: �C..:. - 4.7 t. ,.rr Fx.. : C•- ,
Certificate was signed°bar, - ,".. .:. - M.D.:�:.\„. _ .C- ---
Address r( _l/---�A--7 __ --sa-a...
Place of Burial (or Removal) rZ p '3-- - ,--`— �-
(If body is to be tern o arily held, in spa'�e later) txi , :..
Cemetery .� .... c`" ... -:4:5.:-gr.-.?:. 4. Date of Burl �� � /l-) 19.. 4.-
(If body is to be temporarily h ¢,fill in space later)
Thn Certificate of Dea 'containing the above stated ticulars, 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 eco d with the abo a stated Registered
Nu. , a HER B the basis thereof I Y GRANT A PERMIT �
f• rr __ N j � A (Addle'ss)
the..�ki�"z�i'' to hold temporarily and '� `--( the body.
(1 7rtaker or progri baying char of corpse) er Int ,re ore,or of se dispose ofto how))
Dated �._ r-7' ,l 2 19 3 (Signed) U Li../
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (.abject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
I
ENDORSEMENT OF SOCTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of CO ° bwas 19
(Interment
C A
Name of Cem, e , C mn o Su , e
t (1 +�
Section • Lot No. 1 Grave No..4
(Signed) ( /1 /14141- f_.-
reon'in"dbsFge.e tf—
Address 6 V
, / r_CL'e--
Person in charge trust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF 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.