Palmer, Kenneth Form VS.si NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFICATERF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.._..3_._7._
Village
Dist. No. cif County..kSd e"- -^---t^-'v_ or City - ., Q�f--2
(If '1.5, give street address)
Name of deceased Veteran
Single, married, widowed, (]f veteran, give name of War)
Sex '' olor U.� or divorced (write the word)��........ .. Date of Death 1� z
Age ... Years..r Months .,....Days jace.)....1171-11.„.....epl ..'
Cause of Death G . e-,
Certificate was signed by. M.D.
Address ..! -' r.' :`re`
Place of Burial (or Removal) � �..l" 4-1*-4"-4-4.-42.- j
(If body is to be temporarily held,fill 1space later) /
Cemetery .--j-i— �,-f'..... .,,r2..,-.1...._ Date of B ial 67 19 `'
(If body is to be temporarily held,fill in space later)
Thn 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 above stated Registered
Nu�and o the b . the�f I HEREBY GRANT A PERMIT
----------c-'- --"--.....t"-- il---' -4 3:11.-Cire--14 .... .:
(Address)
.--11-1 *--2....7
'the -- ,rt.:4.-.2-1 4 -t-� to hold temporarily/-nd u the body
(Undertaker or per on having eharg orpee) ( (In re r, �or orootberwi suose ofYstate bow])
- 'Dated �2 19 ° (Signed) ( A ,•(-1,h",,..� R (-�1-..)... . 1...
This Permit is sufficient for the Removal and Interment or Cremation) of a body to any part of the State .abject 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 / aC: 19 E '
(Interment oremati
://<- 3 e''.---*)//1C.' l'1?-s-•-..---i•---- -- ..
(Name oP Cemetery, Crematorium, etc.)
dn.- - - --t'
Section Lot No 6 N Grave No.
(Signed) /2 4 .:. ...\ 1.- .
(Person in charge)
Address YG L l-, _'"'" -V---
,.-k5/ t '''. 55.' (7n ,
Person in charge rust return is Permit to
the Registrar of his District w' in SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF 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.