Alquire, Robert Form Vs.iL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 Resist No._ .._...._....._.0
Dist. No (��ff.U/ County or City /.-"7""-•
-
(It city fve street address)
Name of deceased 7Veteran
Single, married, widowed, .. (If veteran. give name of War)
Sex / . ... /for `� or divorced (write the word .. �� ` - �' .�..Date of Death / -f 19 l'3
Age l 7.Years ., Months Days Birthplace
Cause of Death X)�r`--'2-rx
Certificate was signs by ( �. ..� .‘ l•mr :1 c! M.D.
Address....-' —Q
�c�
Place of Burial (or Removal) '`---7 • `-
(If body Is to be ari sp ls held,fill to ace•later)
Cemetery --- `'�/ —�� Date o Burial��l — / 19. j
(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 Reco d ith the abo,p stated Registered
Num and on th ba ' hereofi HEREBY GRANT A PERMIT
(Address)
the to hold temporarily and the body.
(Undertaker or person having charge corpse) (Inter,remove or otherwl�soose.o4[state howl)
Dated - 19....r j (Signed) R IQ—��, 114J�
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an 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
PREMI SES ON WHICH INTERMENTS OR CREMIATIONS
ARE MADE
/ •
Date c was 19 k
(Interment or Cremation)
je / e_ ('
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) ter
(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 OFrH,NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.