Dunlavey, Robert Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFX44.,OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered
Village Ail
,1_1„, -
Dist. No...5..19..cli.County. .4 ..6?-2-4(e-14-- or City hie4
,,,
(-) (If city, give street address) / 2., /Az 77
Name of deceased (4/!).of .*. sZ44.0-kieet,z, Veteran 1----e--'"1 il 1.1
(If veer1,Ative name of War)
Single, married, widowed, a.77.7.41i
Sex litl "Color 4W- or divorced (wnte the word)-2-2-7 Date of Deap-i °6--- --t<- /L., 9 A .
Age 4-f o...Years_,7. i /.. M:fths pays Birthplace Sa4e-4-14.-afteLb ily-1
Cause of Death --/q--..G; '-ot '
Certificate was signed by ,....Z M.D.
Address .4a-t--.7
Place of Burial or Removal) J11--t.. -1,--..-,7
(If body is to be p racily held All in space later-M2 1
rf
../'. , „,.... i
Cemetery ,.../-41-L, 2/..4.-r,--“. (..„4-142, Date of Burial ./?...).1,---4 / li 19 4-)
(If body is to be temporarily held,fill in space later)
ThA 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 %4nd.c.e.= has' thereofl HEREBY GRANT A PERMIT ii-
,t,i.. .:-/-.7 CY L74,Zec, )? 7
the / /1_ me)
L-44.1, A. .-.4-x--- to hold temporarily and --A-- (Address)
the body.
(Undertak person having charge of corpse) (Inter,.,c,move,ot4therwiTidisnose of(state bow])
Dated i.3 19. L3 (Signed) , 'I)
\ Local Itegistrari
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (oubject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Tranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-1:7)
Date �' li ( ' C // ls/
(In,r1Z-OT r Creme/))
1 /A"--.-- ...--'Z<—...-- 7: ;:::::----
(Name of Cemete8 , Crematorium, etc.)
/./44-e .4,-) 4142-.
Section Lot No O Grave No.
y
(Sign r% 0.. , i J4.\..._ 2ic
(Person in charge)
Address �' l.� . ), n
. LA r›-
Person in charge must return thermit 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 cords
"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 relatilve to the return of permits
are liable to a penalty,of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST ON'N1.NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.