Hammond, Baby Boy Form vs.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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'.0
0 Village / f Q -, ', `i, 1/
Dist. No S b Coun w���`"� or City
(If c'ty,give street addree
Name of deceased61 a ,', ) Veteran C
Single, married, idowed, (if .c ran, e( ° nee j 19) -3
A. �r• g J
1511.
Sexes" Color ` or divorced (write the word)..... Date of D
Age Yeas Months -.3... .Da s Birthplaces/`' 2-'t''`'tl ' a......
Cause of Death �', ' c�t&K .... ........ j^�-.i ... --'.\ 0„ 1'7 -�
Certificate was signed b '�� J�7d...1„e M.D.
Address l
Place of Burial (or Removal) q -cs, A
(If body 1s to�porartly held,fill in space later)
Cemetery... —V .....( .,:c...t.,, . �.R.nlltl, • Date of Burial .. / 19 G'..
(If body is to be temporarily 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 Record with the above stated Registered
Num , and on the bt9MI HEREBY GRANT A PERMIT h2.4._ �j � `2 7
Seddress)
the .r 97' to hold temporaril andto
the body.
(IInd ker o rson haying charge of corpse) (Inter,remove, r otherwise s'mose of[hate how])
Dated 1..:: 196. (Signed) Lr . -
R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate eabjeet 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 S1,'XLUN OR PERSON IN CHARGE OF
PPBIISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
•
Date ^% was 19
,..^� (Interment or C emati
Name of Cemetery, Crematorium,et
Section /f Lot No! 5 f 7 Grave No. /Q
(Signed)
(Person in charge)
•
Address lam' .."Z4
- .
Person in charge must return s 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 OFFF.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.