Cooper, Drurie -,_,.z VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
__ This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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
_ / Village /°
Dist. Not .S! ....COunty... .e �S'....r✓' of-City' ..... ....ic: ..c..4..f....
, f (If city, give street tress)
Name of deceased. 2244 ?. .`,. 4Z:-ra. '..e..: ......... t Veteran, 42:
( veteran, give name of War)
Single, married, widowed,
Sex.32 ...Colork,,,. ... ....or divorced (wnte the word) Date ofpta 19./:2.
Age ,1Z) Y Months »...Days Birthplace...! .12 s 14t it
Cause of Death c. ..(L..:t.. .:.. :
Certificate was signed by st.k. . / M.D.
Address ) . ' . ... :Y,
Place of Burial (or Removal)... '....e.. .14. .
(If body le to be mporarliy held,all Ins later „/_
Cemetery.. ..d.L.4...Z/..Z.- . Date of Burial.:Y; � 1
' X7
(If body is to a temporarily held,ell in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful elcami-
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
Number, and on thiejas' hereof I HEREBY GRANT A PERMIT ( 47..iiii.61.4....,taiiet.44/
..4.. 4.4?. .7/.:
me) ddreis)
th to:V c, ,r,.. . .... . A2> to hold temporarily and ' odY
dertaker o reon Taring charge corpse) / (Inter,r o ,o� tberwise(Renee of state l h
Dated ,... 19(0 (Signed)... .IGaC.!4..G.6�Ll.. . • . :f .?.4:U.-ar'- >...G. .
Local Registrar
' Permit is sufficient for the Removal (and Interment or Cremation) of 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
I Date ;l L was
(Interment Cube)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Y " Grave No.
(Signed) G � .c'- 'tea
(Person in charge)
Address
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 OFH NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.