Serandie, George Form vs.!IL 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. * .._._
,.
Dist. NoP e t" ' Coun LA- C�>r oriCity �"- ""+� C?�.�4 '�� r
(If c1t3, give Street address)
Name of deceased.......... A Veteran
/j�� Single, married, widowed, j, (If veteran, give name of War)
Sex `/, G Color or divorced (wnte the word). (Ai -1A44-0-i.Date of D th....`0...o�..%-.19 6 3
Age LP..f Years Months ............Days — Birthplace il
Cause of Death...:,t1 1
64-4--44-4 7r..a.r�.c.46-c-""
Certificate was signe bd y. . .!7".�:.. M.D.
Address - y,
Place of Burial (or Removal)..( � .- V.' �`'� .., re-1-1�'‘...c Q 0 t-(-�i•(y�.. ill.
(If body is to be,temyorarily held,fill til space later), ( I
Cemetery.....V..)..,.c..-.:i..:...ti' L 'c-<Wit= 4,,,2,,,,yy!�, Date of Burial 47)1,04 .3../ 196..a
(If body is to be t mporarily held, fill in space later) `�
Thq 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 abovestated Registered
Numb
er, and on t\-airim.4..k...„.he baj3sishereof HEREBY GRANT A PERMIT / �� 7���, � (Nami.j ...}.--. I (Address)
the 4 C, to hold temporarily and the body.
(undertaker or person havin charge of corpse) (Inter,remoy or otherwi dispose of[state how])
Dated ``Yhi '`-- �j... ...19.( ., (Signed) 0 1 - C.-kJ £ '►!4- „
al Registrar
This Permit is suu1 ent for the Removal (and Interment or Cremation) of a body to an 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 was / 3/ 19
(Interment or jay-fit+`
(Name of Cemetery, Cremetoriu ettc.)
Section Lot No. Grave No. /
(Signed)
(Per 10 charge)
/
Address Y eC �-1 C .%'4&L.
,_„„A0
Person in charge must return t is Permit to� J
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.