Robinson, Walter Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit cast 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 CERTIFICLk3E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK- Town Registered No.........3.
No nVillage
..
Dist. .519...County Z.-d V. 7.—
Name of deceasedeetli..) A!' d-441..-v.-0---4- (If elty,gtv- --11---1- r---e str address)
Veteran
(If veto an. give name of Wax)
. '
Sexii..i.h....Color.e?..14.ge..or divorced (wn Single, married, widowed,te the word)/eil,444.1.4i Date of"p9eath 4" i..5 x...2119 4 -
Age. 9 0 gars Month . .. .Days , Birthplace. 1
77/
Cause of Death -e
. .
Y"54-164--1,,, _
Certificate was signed byr,,, M.D.
Address
---;-- --e---6,
Place of Bu b0 ri (or Removal)
(If body is to porarily hgld fill in se t )
Cemetery ---e-4-4..:C"L.2,1.1.1,4-7 --€41- Date of Burial 4',// s-- 19.6.'3
(If body is to be temporarily held,fill in space later)
Thft 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 cord with the above stated Registered
Nu7112-4,:dinerettebis t17.47:2? EREBY GRANT A PERMIT
to—. t. ,
•• ...)
the - " -i,.,-del.A.--trit-"•-)t to hold temporarily and ..•
........ ,. ('..the body.
dertaker or persoWaving ehargeAfiorpie)
ir.
I 19.6. CP (signed). ..),zitriicTaVcieinoy•gt Ar disoose of[state Aar]
' v. • ez.--14,--et-e-C-e
Registrar
Permit is sufficient for the Removal (and Interment or Cremation) of a ..•y to any part of the State (=Wert 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.ot2 °,, � ,�� �i—�'5 is
Interment . €.y_, )
(Name of C ye em ttorium, etc.)
2'4 Ltir-7.--_. fs
Section Lot No. Grave No./ 2i
(Signed), . z- t✓ - �'�-GAG•-''`L
(Person in charge)J
Address -' �� a— i� �� '>
Person in charge Dust 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.