Shippey, Ward Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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.__..f-
5
Village
Dist. No.. .: ..7Couaty..1,,4„� `^ oreW
(It city, glv treet dress)
Name of d eased ~ Ig UZ 1)S.r;:l f I PT£ Veteran
i Single, married, widowed, (If veteran. give name of Warr
V. i 19.
Sex::, ...:ColoA .cc..:.. .. ..or divorced (wnte the word)` Date of ,-2f)1.1
Age �..Y ars. Mo "s. .Da Bi .1.g _, ,J ���a..\:ZS4lo. . -' '
Cause of Death- ., ..
Certificate was signed b T./...G � M.D.
Address �J —Z..,.. -R.
Z�/
Place i toB tem dor Remov i `ter)...
(I!body is to tem drarlly eld,fill ins acglater) I ! / ..--
Cemetery
-- ' '- .' . ' :}.. Date of Burial �t l
(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 acce•ted the same for registration, have recorded it in my Lo Record with the a ve s ted Registered
N - • • on a ereof HEREBY GRANT A PERMIT \
to
y� (fQ�@sa)
the ' 7 �. to hold temporarily d K..4. .the body.
(IIn stater or non having cbarg of corpse) (Inter,remov ototbe ss✓dismose of(state h al)
Dated 19 •> (Signed) .'..& '1✓`_-1..�.0
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any pert 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 SExiUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Da fi'� was 9 ��
Interment or
(Name/of Cemeter Crematorlum etc.(N Y, r )
Section 377
Lot N Grave No.
(Signed) 7,..„.4:e. e-s---4/14
(Person in charge)
Address <) G' l
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
VENT, 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 OFIchNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.