Chadwick, Ethemel forms vs.111. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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. Town Registered No.
Village
Dist. Nca..9....county.11.,. .tr—) or City
Name of deceased (If e'ty,give street add )
.- G144-411;...,:e--/C../. Veteran .t...-ee)
(If veteran. si e name of War)
Sex.attea..:ColorVieSingle, married, widowed,or divorced (wnte the word)44.).--t:44.,:e,-OdDate of e '. .._"2.5;-- 1964-
Age..r ars . Months ys . Birthplace. ,
Cause orDeath 7.2" 11-a
64.5,7,-,,e_
Certificate was sign by.. . ... C.4....n-k.f..--...4 M.D.
Address ta.-04414.-er-t-. C-77?, '
Place of Burial (or Removal)..... . 4r1,:-....
(If body Is to tempor rilyilel ,fill in space later)
Cemetery ‘e". "..,1 .44,-- Date of B rial I/--- ..C4 0 1944-
(If bodi'is to be temporarily held,fill in space later)
Thq Certificate of Death containing the above stated pa iculars, 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 ecord with the above stated Registered
Nur opul on, .. has' th f I HER3BYARASNT A PERMIT 7j--
to. f't-- -C- 7
7 Na j / i (Address) . r
the' Tr.-6,....6. 4..ef.A....--igrAl .. .........__to hold temporaril and ( e body.
dertaker,or rson having charge of eyrpae) 40P (Inter,remove,o.e. 'mese of(state how
Dated. 2--2 19.L 1--% (Signed) / , ,.. • - - , At,
1110 ! .47.,,,,,,r etigtraz
ermit is sufficient for the Removal (and Interment or Cremation) of body t!'any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which e a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date 7ao Z l �►�7' c ly S"
(Interment or Creme ion)
•
(Name of Cemetery, Crematorium, etc.)~ t
Section Lot No. Grave No.
(Signed)
( raon in charge)
Address /t/' G
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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.