Harrington, Curtis Form V&sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
__ 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.__./... ..2.
/' Village 1 �_ "'"y /�
Dist No 45 Cl( County....W �'"� "J� or City a 2
pp (If city-,give street address)
Name of deceased l--'�A ..:... .... .. .... ..... ..... ....' . Veteran
ii
Single, married, widowed, • o� (If veteran, give_name of war)
Sex Color or divorced (wnte the word) V( 1 ' Date of D th '. 19 C -3
Age : 1 Years Months.. Days --Birthplace J .., T 4/
Cause of Death 4111 .5 -^"- ' t y�, p�
Certificate was signed by .. .,� y�,, 1C11C1 M.D.
Address r J, .�..9 �. .f.'� i �,
Place of Burial (or Removal).... ,..: :. .. ti�r ,—ti"v
s
(If body Is to be porarily held filit in apace later) /
Cemete ,-<.. t's.>....�,' 't-k Date of Burial `' 19
(If body Is to be emporarily held, fill in space later)
The 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 Rei ord with the above stated Registered
Num on the basis thereof I HE GRANT A PERMIT ",„,,,,,V121...4.A. ' j4
to ...... . EBY� �!lr�-cam'" je:s
Na ('
the ' -t� y" to hold temporarily and C�' (Address) the body.
(Unftttaker or pe n tukving charge of corpse) (Inter,remove or otheZe di Dose (state howl)
Dated LI 19.a (Signed) _ `�'1'1.
al Registrar J
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to y part of the 'Rate (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 SI X`lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
/13 Date of ( 19
(Interment or.
(Nsmrgf Ce eter Cre torium, etc.)
(:11/.ele/6"--c--()
Section Lot No. /7 Grave No.
(Signed)
(Person in charg
Address&41,?/) c„,
l
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 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 OFrH.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.