Berry, George --� VS_di. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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.__.._.'
Village-.
Dist. No. ..�Coua .a.!U)..!? �. or City ..4.ttl-' .. ti,.,.,c,.,,.
(If city, give scree reel)
�T e of ceased ). .1ZC.,.j. .. . yVeteran
... .... . . .
Single, married, widowed, (If v`"r`n' give nameof War)
Sex. . .. . ..Colo..�. ..or divorced (write the wo ).. ... .. . ........Date o } . . . .../ 19
Age ars Mon p c ... ... ...
Cause of Dea : . . --
Certificate was signed .B . ..,. Mt)
Address ... ... ' ...
Place ofBurial r R al)
(If body let e,te por ,fill 1n space ater
Cemetery .. . Date of Burial / " 19.b.
(If body Is to a emporaril y ld,fill 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 a cepted the ame, for registration, have recorded it in my Local Record with a above stated Registered
N ber the 'as hereof I REFIY GRANT A FERMI ; •/J
the..:. -'i�<' :: ).. to hold temporari0 d the body.
(Uri ertaker or rson having cbarg .of corpse) ,e; rater,re• ve; of erj a dispose of Is owl)
Dated i — 19.4,3 (Signed) ;
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a ...y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 9was • le 19 G%3
(Interment or Cre ion)
(Name f Cemetery, Crematorium, etc.)
4aZion of No. G e No.
(Signed)
(Person n charge)
Address GP d . /4 (o o 0
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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 OH LNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.