Preston, Kenneth Worm VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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. Wwp Registered No .A.. -2,...-,t7..
Dist. Nof.4-'c'7. C")l County --- ('---a, ------!`--
or City ....,
. f (If city, give street address)
Name of deceased .t.'''.---2"t-r:2:: -- -X.-----7 -77—a---‘2,7.-- - Veteran
f
Single, married, widowed, /1_,
/ (If ',terse. ewe name oWar)
Sex -_y2 7)Color ' -- or divorced (wn
tethe word) Date of Dpath. .)Y,'"7 / 19
Age. Years Months A— .Days ......_„.—Birthplace .,*--1-4----* lw...,
./
Cause of Death --.4-74 - --el'--ic-- ,-tr—A.---
. 4 ,....<
Certificate was sign b . ---ei. - 79_, et.-. M.D.
Address -2 ' f---\"A c,—edi'--?
Place of Burial Cor Removal) ...--2;,_ e;(If body body is to be tem —r)irily held,All in si:956 later)
,
Cemetery ‘..-- ---' ?- --'1-- ' --(-7 Date of urial .1-77...Z.: 1 .74 19 I-- -)
(If body is to be temporarily held,All in space later)
Thu 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 L, Record, with the bove stated Registered
Number, v -(
9151 on the basis Oereol.3,7REBY 9AANT A PERMIT __6 //';'-
,
‘c---C-Z17, / 7.
_,--........ / 4 „...___Veti )„ ,..4.:..... --- ( dress) -'
the ‘`."--A-t-- . 7 -- t'-- ' to hold temporarily and -- e body.
(V4dertaker or pe n lagying charge,of rpse) (Inter,remove or otherwerr ,cystate how )
Dated "7/21----0 -6 19 ---7. - (Signed)
%''S...
Ft
This Permit isJ.ufficient for the Removal (and Interment or Cremation) of a body to an part of the State (aubject 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
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date_ail'. 19 ‘.
75
(Interment or
i<
(Name of tery, Creme Coquet, etc.) ,'
Section \ Lot No. /4 a Grave No.
(Signed) / �` Liz✓ �..�I �'z' �t
neon in charge)
Address
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 cords
"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.