Hodgman, Charlotte Form VS.4I1. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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—. ...... ...1(.... ......
4 ,
Dist. No,... .&a./...County........71....e44.A./...4-41 Village ...,(706.4ixi c..74____A,..e4
or City
i .
(If ey,give street address)'
Name of deceased.....Z2d4./. ajli."1.e../- Veteran ‘724f
S 4..?Color..bire..
ei...4 in.gle, married, widowed,
. r divorced (wnte the word),0}'-
., . .. ....Date o
f.jeilri.e,(If ye I an, give name of War)
. "I .4?" 1 9.41.
Age Yearsy Months ..:e.;.0.222 Birthplace. . AZ& -
..).
Cause of Death. ....... 4-1.,,,. . .. ... ....62 .
Certificate was signe4 by.... ... .6;.i.6 M.D.
Address. ..-,-c.44.6.4. : . 2
. .
7c-
Place of Burial (or Removal).. ....1.:77es&xl.,. 7 ".....- -407.,_
(If body ta to be te -1) aOly held,fill in later ,
Cemetery.. ....,.......4.44e..ei Date o Burial. e .... e." 19.6&
(If body is to be temporarily held,fill 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 ecord with the above stated Regist
Nu.. . . . on the basis thestvf I HEREBY tre_N;,I," A PERMIT
to ---: -1%A. X)) 0X- ,
11::,4e=s))
the to hold tempora ' and the ody.
(Un ke r Dated pervn having charge47e) (Inter,rmor othe ditt,Is te how]
. • (Signed)
al II
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to ny part of the Slate (eubject 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 ras - 19 �;--
d:. '
(Inter..ont or CI...me
-e
(Name of Cemetery, Crematorium, etc.)
Section / > Lot No. 1 Grave No.
(Signed) Q"
(Person in charge)
Address !
Person in charge must return this Permit
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 v.ords
"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.