Coon, Ernest Form VB.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) is which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERT FIST OF
DEATH, LEGIBLY WRITTEN IN URABLE BLACK INK. Town /� Registered No-�F-••./---.....__
1/4
Dist. No S. County.......... --- ... or C
(If,"t , give str ad so)
N• . e of .eceased ali E.S r 40 Veteran
/ Single, married, widowed, q ( veleta give name of War)
(@
S .V• •.: —Col ..or divorced (wnte the word) Date of a . ... /��..,..
Age a ... ars ... nths .Day place
Cause of Dea . . ... �... .. ...��.�/
Certificate was si ed aril( '‘ , M.D.
Address..... .1.. •. Q F
Place of B ".1 or e ) vYa -(If •body is to . • ri 1 1 space la r>
Cemetery.... oh, .... .. . , ate of Burial /L219L—
.. ..
(If body is to .e •Dorarily he 1 in space later)
Thu;Certificate of Death c aining 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 ccepted the s e for re ' ation, have recorded it in my Local Record with the above stated Registered
N on a is thereo HEREBY GRANT A FERMI
to.... i
' (Name) ( dps)
the to hold temporari and the body.
(Undertaker or person having charge corpse)
Inter,remove, o e 1 nose of[state how])
Dated C7....... Z� 19.. 3 (Signed)
R
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any past of the State (subject to local
cemetery or other regulations),unless removal Is by common carrier,in which case a ansit 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 3 19 42
(Interment or 8wimobbnj-
(Name of Cem tery, Crematorium, etc.) 4� J'r �
A0/Pr', ,S .►/
Section Ara Lot No. Gam: B
(Signed) n Cet.A.A.) �'L. /"r in charge)
Address e i� � �' ��•�`�
/////'
Person in charge must return this Permit t
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.