Alber, Clarence rorm vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sa- This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Pillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No...
Village
>ist. No 4 County........... or City
1
(If city, give 7 n t dress)
Jame of deceased.CAVIre-s-ree-L------' 4 C?.e°e‘-eJt. Veteran 1 '•-j-e-411/ all
Single, married, widowed, , (II 4/van. give name of War)
>ex...WaeecOlOr C•fef or divorced (wnte the word) 7IVrteQ2-4/2-'Date of Death i
age ,575— Years Mo ths — Days Birthplace. ,11.....e.-eft-4"- -a.€1240-,--)77-4-424.-
:ause of Death (Z? /
.ertificate was signed by b
. M.D.
Address
.. Z:j.1-4._iic,
)lace of Burial (or Removal) 77-4-0.-a-...-- N./.4.4.4.4../..--- .C.s2....*A.-.; ...,..4 , / ''? ' •Yi -
If body is to be temporarily held,1111 in space later)
3.-.-..t,....4L44.' 6 4 d-x.i...4; Date of Burial. 5 1943.
If body is to be temporarily held,fill in space later)
lie Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
lumber, and on the basis thereof I HEREBY GRANT A PERMIT , ,
D /1=k (zia fv(4;';i4t., cgehC 4-'-' .. j0A-fr . - (.1--e4Le
he.... v '';'. .. v2.5......- to hold temporarily and z --.10.4,---. ( dress) e body.
' (Undertaker or person baying charge of corpse) (Inter,remove,or oth se di se of[state bow])
dated a..t.44. ,..„3 19.4 (Signed) , .
al
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodyf,to any part of the (soubject to local
amatory or other regulations), unless removal is by common carrier, in which case a Tetnait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of,i ?t..- wasC :ee 19
Interment or Cremation)
r (Name of Cemetery, Crematorium, etc.)
Section Lot N . Grave No.
•
(Signed) / ;(7.
(person in charge)
Address
e ., •
Person in charge oust return this Perm to
the Registrar of his District within SEVEN (7) DAYS
fran 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.