Winne, Walter Form VS.Si. 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. Town Re stered No.__.._ce
........_
Dist. No.�..4.Ql..Coun Village .....„..„,,kze_ie., `��� � '
ty..... .� f al or City
(It cltJ'. give strenf Zs)
Na of deceased... . ..4 Veteran
/L��'�.Single, .ed, widowed, a dd� CI etersn. five name War)
S . . olor.R.i.)&.h or divo ced (write the word). . .. . ..�CL./Date of Den .: ' 19
Age...7 7 Years Months Days G Birthplace.... . . .� .r•+••••
Cause of Death. . .. „e ��
Certificate was signed y....`.': ....... ..ti:. 2,.,.•.•. .. . a � M.D.
Address... .. . .,67'.,i ram.,.. - ... ... ,ems �7�f... . .
Place of Burial (or Removal) ....e.,-t,G f .... . d.0 ,
(If body is to be rarity h sp ce later)) ,cam
Cemetery...a2 ., :J'l. t?. Date of urial... . .2 19.4.
(If body is to be temporarily held 1 in space later)
The+Certificate of Death containing the above stated particulars, having been pr sented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Re istered
Noumq� on the basis tihet f"I HEREBY GRANT A PERMIT r____�
'� a ) zo ( ,
the !� to hold temporarily and .the body.
dertaker or person ving charge oo�f corpse) (Inter, o e,,,or otherwise dispose of Irate howl)
Dated... .. .4a7 , ( 19..l�.. / (Signed) r c/, ,1 .���' :v_ y
Local R• .
Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ("abject 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 SEX'IDN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of"--
was(Interment or Crej ______".....h1“:1
)
D
�r
(Name of Ceme ry, Crematorium, etc.)
Sectioi' No. gave N�
(Signed) • A,.
67a,,,,O #. 4t_47-'
( rson in charge)
Address §:)
6 ��� 6 �' Q
2Y--c-------,, a
Person in charge must return this Fj rmit 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.