Vaughn, Baby Boy Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir This Permit can bs 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._..Z. .-...._
�� Village /
Dist. No. .. 1..County.........f.:.�1E.�Y?� or City N�/� i
1 (If city, give street address)
Name of deceased... a- /..(7,�.....�0:(,7..,l�a i% ��
Veteran
� Sin le, marrie idowed, (If veteran. given a of War)
Sex..247 Color �1' or divorced (wnte the word).. late of Dea j ............../ ..19
Age Ye��S.�. ......f, °�-M- onths Days Birthplace ... yl
Cause of Death-...C.rt:a..c'-'w�csr'lir'l;
Certificate was signed by ., J ",..,........ . M.D.
Address ��� , `-
)7.
Place of Burial ( emoval) 7/1.4..N.....,�1.... e--r�l - � /7 Y
(If body Is to be po y held,fill to space later), G °
Cemetery '�?' :......�./..C. /
Date of Burial ! s 19 t-
(If body la to be temporarily held, Jill 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 Record with the above stated Registered
Nu on the basis th f I HEREBY RANT A PERMIT /�
to f146 :. ..a. .. ...cit-�'... .. S,.n:1�:tr: - - ....= y�L:(L. >
/ % i
the �l � G..a—..:C 4 . . 'L to hold temporarily and ,.,, G„ (Address) yy' the body.
(UndtrakeF or pe a haviag.cbarge of corpse) (Inter,remo e,or othe se dlsoo of rotate bow])
Dated : 19. ...� (Signed) L —(
al Registrar
This Permit 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),anle.a removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORS MENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date J w ...( / /4 19
(Interment or on)
(Name o Ceme a ymator um, etc.)
Section .Z. Lot No. Grave No
(Signed) 73/
(Person in charge
Address
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 wards
"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 %TENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.