Koble, George Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ssr 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. 'jam Registered No._ ..__..._........_
Dist. No iir/Co1uI7.---. e
s C
-
( efts, give st address)
Name of deceased.. IX-""G -�-- Veteran VVVVVV /�;/_Q
`� � Sing1 married, widowed, I (If ` ' given e f Was
)�/r
Self.. .Coda or divorced (write the word)./� ... Date .. . f 4. .... 9.0-sf
AgeZCertificatew::
,Q.. rs o the .._ .D • lace ��:. r•�•���
Cause signed by e M.D.
Address .P. is �� fP
Place of Burial r Removal) :(:,: -' ..W
....,. ,...6: t
(If body 1s to to orarily held,fill In e t ►
Cemetery . . �ir ?2r� Date of Burial .. .. t l 19 6,
(If body is to be temporarily held,Jill in space er)
The Certificate of Death containing the above stated partic s, having been presen ed to me, after careful exami-
nation, the same appearing to be COMPLETE, CORREC , AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for regi tration, have recorded,it in my Local Record with the above stated Re i to
Number d on tht,basis f EREBY G NT _Fp(RM e - /k„, a'
the. ... . ... ....to hold t mporarily a• )- t od
er er or ving charge }�.e) �• •• ere,or otherwise �;goo w])
Dated `e 19.. �j� (Signed) f... ...
e Registrar
Permit is sufficient for the Removal (and Interment or Cremation) of a body • y part of the ( jeet to local
cemetery or other regulations),unless removal is by common carrier,in which case a Tr • Permit (VS No. 62) is required.
ENDORSEMENT OF SEX'lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
i
Date of '"',; , was (^'
(Interment or Cremation)
Zak _
(Name of Cemete , Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in charge)
Address 1 14. N 6+/1_,711"
11
Person in charge Heist 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 iu located. 4
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.