Woodward, Harold Form vs.QL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
er 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. ...3_;a L_
County I Village �.2 - "9 `
Dist. No f 4`' Coon z t--;` ">.�` or City l // ,....
//�� , ( J (If city, ve street addifse)
Name of deceased...l. �t /I,/ - Veteran
Single, married, widowed, ) (If veteran. give name of war)
Sex _Color ' or divorced (wnte the wordy Date of D ath � - 1�
v
Age '�('-`5 Years Months .Days Birthplace. c`-`� Y'-'
Cause of Death L, ..,\` , ..pr?J`'� (
Certificate was signed by` Lp.. . M.D.
Address.....:,
Place of Burial (or Removal) ,'i/!! ,,.2) r: a.t-&- .----
Cemetery
(If body is to be tem{rarily helms elfin space lat )n
...... -- -t- ' -G : . ... Date of Burial 7 5 19 &,
(If body is to be temporarily held,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 accepted the same for registration, have recorded it in my Local Re ord with the above stated Registered
Number, and on basis,the I HEREBY GRANT A PERMIT _ t,_ ,
z-zr:,--' -''
the --1 '\ : to hold tempora and the body.
(Undertaker or pe having charge corpse) I ter re ore,or oth se dispose of[state howl)
Dated 7 c 19.. (Signed) G.-+ .> 'vL
'. Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (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!PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date q /,� t` ` �.�J 19 K'i3
( nterment or rem"ation)
4 ;;;?//
(Name of Cemetery, Crematorium, etc.)
Section Z Lot No. lr 72- Grave No.
(Signed) ✓L / ._ C. ✓.. ''.,��
(Peen charge)
Address 4 C
Person in charge must 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 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.