Barber, Clayton Form VS.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
U' 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. 5. .
Village vi ' ( '"
Dist. No County... ... or City /Jb� . ..C.,/- 42
'—'� � /� _ (If city, give street addree
Name of deceased ra �jV'`�` �— Veteran /YO
I A I Single, married, widowed, (II veteran, give name of War)
Sex !,►',,`' Color....Vl.' or divorced (write the word)..�d t'�-Q-t Date of a ... ..2.?�:.19
Age . - Years Months Days Birthplace '�t i,-f
Cause of Death..... .. t
Certificate was signed by.... .. . {..�•+ if:. y-40.--. M.D.
Address -�—'� .... . ' ri .
Place of Burial (or Removal) . . ••r•�•
(If body is to be m racily OK, �i) space later)
}� gyp
Cemetery 4. " ( .:.. '''�' "�'c`� �G �Date of Burial .... ,� 19
(If body is to be temporarily held, fill 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 accepted the same for re 'stration, have recorded it in my Local Record with the above stated Registered
Nu , and on the basis th f HEREBY GRANT A PERMIT c
to.,�. . . ' t -�' .461_,,t,L4i.
(Nit
i ul��1ddreas)
the �-`" { AQ,.:- -......�..to hold temporarily and the body.
(IInd ter or perso aving charge corpse) t (Inter,re ov ,or oche disnos9 off[state bow])
Dated \ ..4 19..6i.3 (Signed) 4= .. .... k., �L..k,...�:z'� l!1/\
al A J
This Pe" it is sufficient for the Removal (and Interment or Cremation) of a body to ny 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 POISON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREIIATIONS
ARE MADE
Date of was / 19
(Interment or Cremation)
,
/
(Name o Cemetery, Crematorium, etc.)
Section jV °- - Lot No. It-60 'Grave No.
(Signed) 42.04‹.
(Per n in charge)
Address 6 Q . 6 O 0 ) 'ff4 �.
Person in charge waist 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 `'ace 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.