Hammer, Walter Form VS.41. 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 CERTIF CATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No,—../...1.... - -'
-..-" Village
Dist. Non t.e0 f County..._ 4At:L0Y or City
/�1 (If city, give street address)
Name of deceased ll.(r" L Veteran -----------
Single,
married, widowed, 1,// a (If veteran, give name of War)
Sex . ..Color or divorced (write the word)......Y.��� Date of De ....... ...lv 19 (i3
Age Years _ Mon s .Days Brthplace
Cause of bath -.. c�' 0`-'
Certificate was signed by alrri.-'2- M.D.
Address .".::: r ... .....2--�x-�� � lif"i/air
Place of Burial (or Removal) -C.N.. /.l
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial °9'7 19.6.=3
(If body is to be temporarily held,fill in space later)
Thi 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 abr a stated Registered
NumbetlAite bail thereof HE-uTEB/j� GRANT A PERMIT 6 AZ fi[ Lj v
(A d u) /
the C to hold tempora ' and the body.
(Undertaker or person having charge of corpse) Inter, move,or:else cliz� qqqo [state howl)
Dated 19 (Signed) i�
Local Registrar (t...1--4-41‘.-
Thu Permit is sufficient for the Removal (and Interment or Cremation) of a body any part of the State (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 SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date fr - .1- waasi'f-)64.
f 19 3
_ (Interment or
(1/....;01:-- 4,3-Zei--.., _-0,..,__c___„/(1
(Name of etery, Crematorium, etc.)
sJ
Section Lot No. Grave No.
t
(Signed) _�G h---- ��(:, ( .
/ (Person in charge)
l f'/
Address X-Y L ---
Person in charge must return this Perm ff to
the Registrar of his District within SEVEN (7) DAYS
frown 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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.