Woodard, George Form V&SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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. %Avign Regi,ered No—..................__. _
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Dist. No-)fat 0 f/ County lid .a---arl- A,-.„..- or City ..---"--5..-- .t._,--- :, ‘,.....4c,
(Zr city, glee street address)
Name of deceased- ,42-2-#----"--471Q-- (*(- 41-e-- -6t-r— Veteran
/2/ th
} Singli, married, widowed, (If veteran. give name of War)
Sex . ,. color or divorced (write e word) /0",_7:
.Date of Death ,
/ - ,/
,.......
Age -,... 7 .Years Months Days Birthplace. :,.r -"4*----/ (-<----...A..... — ..i...--
te -
Cause of Death ..,:-. ---
- .- .3,-.t-...4t.-f--, -•
. r
Certificate was signed by CA-j--'(--= M.D.
Address i 7
...,
.--
Place of Burial (or Removal) 'I
--/--
(If body is to be temporarily 1-9,en in space later) '
Cemetery -- ----(---:),-. .-..-.(.. .4e.--.(...,v Date o urial 1-- / 7 192
(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) rd wi the ve stated Registered
Number,And ten Vim basis th%eof ii HEREBY GRANT A PERMIT
to iv 6 .ffe--c-o•-e-v--V
'.*--i -
(Address)
the --11)-..---e.b.... ."'1X-L-----' to hold temporarily and tlJ.
(Undertaker or person paving charge pf corpse) (Inter,re oye,or oterwl.e‘disnose of[state how])
Dated / — if 19...&_3 (Signed)
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eubject to local
cemetery or other regulations),orates*removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SJflUN OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date .-f _ :: l 19
(Interment or tle tion)
ram.._---�Z/e7:1-6:4..--,
�-�- _ _
C (Name of Cemeter Cremat rium etc.
,111-71 "
Ys � r )
Section Lot No. Grave No.
(Signed) 7/.a-rii 2 C 'Z-C IG�
1 art
(Person in charge)
Address �(f`" i.----(frA, , .....V.Z...7-4 _,.-#40,----e____
Person in charge ITust 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.