Rouse, Baby Boy Form'EL el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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, LEGIBLYWRITTEN DURABLE BLACK INK. Town Village Registered No—....�.__....._..._.....__
5 fJ '' ) /�
Dist. No' Couaty.u.1 �3 --"�, or City `�.4..) .�,�(-�- u i "/
(if city,give street add s 11
Name of deceased ` �... .. i40--r. ),-,S).._, Veteran /G
�� _ j) \ Single, married, wido (If veteran. give name of War)
Sex /-�VI R Color...ILJ or divorced (write the word). L� Date of 7l. 1 �..
Age., ..� :s...Y -) .Months.. . . ......,...Da s • 1�zA.,, / i2 4-
Cause of Death . .:.��, ,,r..ro...Q. Z......... �� • Q.:'.. .
Certificate was signed by �u-��� „ . u M.D.
121,
Address ,...'. .. .. lA. .
Place of Burial (or Rernsval). y �,,. �, --z--�-ti
(If body Is to be t m�gorari]y held,fill in ttyice I
Cemetery.. . ':,ti.f� . . Date of Burial......c0 — l 19 C`.,5
(If body is to emporarily held, 11 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 a ve sta ed Registered
Number. t,he basia��reof I HEREBY GRANT A PERMIT �c�`/�•� �
the �'x' nave..)
(vn ke or to hold temporarily and the body
person having charge of$ rpee) (Int r, move, otherwise ose ofEstatehowl)
Dated L�., I / 19..6.. (Signed) L ( .. .
Local egistrar
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 PERSON IN CHARGE OF
PRRMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
.47
Date o * - was �' 7 L 19 �s
(Interment or Cre )
,7 ! __
f / 6
(Name of f Cemetery, Crematorium, etc.)
/ C 4
Section Lot No. Grave No.
l Signed) / G �-G 4,er,"
(Person in charge)
Address G G� 2
.
Person in charge must return this Pevkt 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.