Smith, Harry Form VS.4IL 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. -T-own Registered No—--5- 3.--2--
Village-
Dist. Nos/C 6/ County... -..wl--- -60-Airauw or City ,,,e,"/„,,
(If city, give street address)
Name of deceased Veteran •-
ngle, married, widowed, -------
(If veteran, give name of War)
--)._. ' „
Sexid.. /.. ..Color.-.411.1. .or divorced (write the word)../(21.21.144.4, 4-, Date of Death 40-e-cd.., .,2 9 194.3-
Age 7 Yeas Months „ Days Birthplace
Cause of Death 4-.6e.e(at ...-" ,..Al-
Certificate was signed by A) 6 r arteinave",--) M.D.
Address za 0
Place of Burial (or Removal) .?...t
(If body is to be temporarily held,tillrip/apaceiater) A
Cemetery 'Date of Burial J P- - 3 / 19 6.3
(If body is to be temporarily held,fill in space later)
Thg 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
Numb , and n.the,basis thereof I HEREBY GRANT A PERMIT
to si-. 3 g i 1&- I.ern2 40 .186v441 -97-0-14
the —410,--r1 ,ON to hold temporarily and ,e4/1,&,(2 (Address)
the body.
Mu rcairer or person having c rge of corpse) (Inter remi or oT /
rwise disnose of[state how])
Dated ,L) 4'4' .0 19 .,3 (Signed) 46-. --V
Local 11.-- ="
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),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX1UN OR PEJN IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date f �, :o`Iii7' )"e-. ...T / 19 ,Fa_ 3
(Interment''or Cremation)
, J ,.::
Name of Cemetery, Crematorium, etc.)
Section Lot No.‘"7. Grave No.
(Signed) 4-- 1C ti-
Person in charge)
'�' 2 i8e4
aaaress ��
r.
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.