Smith, James Form VS.St. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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...9Z...7
Village ��/
Dist. No County........:`l�..M11�.? � or City ,�::�../f•� L i
!) (If eity, give street address)
Name of deceasedJJ/ Veteran f 2
Single, married, widowed, (If ♦et r . give name of War)
Sex Color.... or divorced (write the word) Date of De 9• '
Age `7/ Y rs. Months .......»...Days Birthplace.....,...-�..;' . , 1 � '
Cause of Death .. r •tk t,-.-e--
Certificate was signed by ... --n zce M.D.
Address yE.. tt�r . . 424/4 )1,
Place of Burial� of Removal) .1.?.... 1. s ,C : ....
(I!body is to be/temorarily held,fill to space later) ��GC
Cemetery t/.•..,.....:•..... '�'" Caul Date of Burial /�,�/N 3 19
(If body is to be temporarily held,fill in space later)
Thn 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 acts ted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbers ont a basis thereof I HEREBY GRANT A PERMIT /J/,
tO Y (Ns (Address)
the �� � - to hold temporarilyand e body.
(Undertake(Uodertai4 or wools havigs charge of corpse) ( t r,remq►e,or oth se disp se Istate hoI
Dated cr„�: � ,fy 19 - (Signed) } fL• o „
. al Registrar
This Pit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Slate (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 SMXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of. 1L ` . was 19 F��3
(Interment or Cremation
S'a"—
_,/
(Name F0‘41A
metery, Crematorium, etc.)
r
Section c � Lot No. co f i Grave No.
(Signed) ../92" • �C C.` _-1--�-/Ce'
(Person in charge)
Address f�" G `' 6� x �--- _1Y.
1 2)9 :.7 ' 52 '• "'-) ,
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.