Ward, Clarence Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t" 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.
�i Villagell r� 0jy ''
Dist. No Couaty......�:.F:. s. or } S
(If city, give street address)
Z�//
Name of deceasedeite27:-&-.g.-.7ar.-gd...0 , Veteran 6/
`� Single, married, widowed, /// (If v cram, give name of Was)
Sex - 21 Color.....Kfr or divorced (watt the word) tic!/ ' '% Date of Death ,-...a.0.r....zz:..s...19
4.3
Age 6a Ye� the .Days Birthplace -0,, C •
Cause of Death
.9 Certificate was signed b ... .e . .,..... :,,,fin-Y�c M.D.
Address - ��-?
Place of Bu?1,or Removal) lL
''',2 Y
(If body Is to borari]y hyld,fill In■pie, ater)
Cemetery... -- L Vi'-.0.,..7 sir Date of Burial .. .. ..,...4, 6 19 1
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been present 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 ecord with the above stated Registered
Number /ma Number,ijind/ma the basis th f I H£R BY NT A PERMIT
to ame) (Address)
-e- N,4' -el-7 )2 X
thew k� to hold temporaril an ... the body.
(Und ker or person having charge of corpse) (Inter,rem e,or otgES�vls�d)s�ose of[s bow])
Dated .z ..... 6 19.]-::,3 (Signed) ' l.4lP�
\S.ocal Registrar
This' ermit is sufficient for the Removal (and Interment or Cremation) of a body to any 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 PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
•
Date o 19
(Interment r Cr tion)
172, ;//1.-Z:
(Name of Cemetery, Cremator m, etc.)
-....-....
Section Lot No. Grave No.
• s
(Signed) G-t ' Z
(Person in charge)
Address
Person in charge oust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above dat. 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.