Davis, Richard 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 aubregiatrar) 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...._../.....L'1
—/,, Village
Dist. No County.....0 �� or City r '�'�'
�+ i� (It city, glee street address)
Name of deceased , ✓' e.,1/F�i:7i-1! Veteran ..`p...�'i:,f
/ir Single, mar(ed, widowed, ) L x (tf veteran, sire name of War)
Sex . Color f �' or divorced wnte the word .Date of Death 7 .19 1-3
Age la 2i- Years Months "...Days Birthplace s✓ .... .y...1.t. ....
Cause of Death --Y; 1a:.. -f.:4"--,
•
Certificate was signed - . ..• , � � M.D.
Address ,27
Place of Burial r emoval) ....�1./?7 .. �-�-� ' /e
(If body is to be tlm ly held,p111n apace later)
Cemetery �. ...t 6 L:....-4.L tP"-1 . Date of Burial N - '-' G 19.e 3
(If body is to be temporarily held,811 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 on the.basis f I HERBY GRANT A PERMIT
to it- r'-i.--i-.-c_._.- '''cl-' )Z7
(Address)
the '""Ace- to hold temporarily and /'1-6--A' the body.
(Undertak or ry
n ravin charge of corpse) (Inter,remove,o otherwise diose pf[etpte how))
�
Dated 19.C. (Signed) . i `' 1
. . ... Local egUtrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to 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 SE IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREdATIONS
ARE MADE
(:
Dater- was 19 6\3
(Interment or C mati on)
(Name of Cemetery, Crematorium, etc.)
Section " Lot No. /lo U Grave No. /
(Signed)
(Person in charge)
Address ��
Person in charge must return tHis Pe it to
the Registrar of his District within S N (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 OFrhNSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.