Bennett, Rolland Form O&u. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 DU,. tABLE BLACK INK. Town Registered No. ..,i
6C Village rl j ���
Dist. No. County.. ..���� — or City % �7
(If city, give street address)
Name of deceased . .. .. . ." n � Veteran
'�,,, Single, married, wi owed, r (If veterans ive name of War) ��
Sex l.L.(.....Color.....1 or divorced (write the word)' 9 .�iT��'x e%Date of De +...1 :..s2 , •I9. . �.
Age ..J..� Yeiar, ;Months....., ays Birthplace - ,'- " ) -y
Cause of Death 4,4) 11'
Certificate was signed by : • 7 M.D.
Address
Place of Burial (o Removal kG(21J ^ `Z` - -
(If body is to be temp ly h sp later)
y��t►Cemetery ��' /�.. . .. . ge:72..:&-‘--a2-e-e-7---,
Date of Burial & 19.�:...Y
(If body is to be temporarily held,; 1 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 Record with the above stated Registered
Number, on the basis th f I HEREBY GR. NT A PERMIT 7
to . . . . g` ,r 4 - .7 G, F-�,e f
—maws) - -•.." (Address),
the ....2� ;,.t-- _- to hold temporarily and....... the body.
(Undertaker or person aging charge of corpse) p y (Inter,rem r or otherwi dlsoose of[state how]) y
Dated .fit.":-/"zL,?' 19. 1.7.4 (Signed) y �
Local Regletrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any 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
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was ati ' / 19 G
(Interment or Cremati
(Name of emetery, Crematorium, etc.)
Section Lot No. a���Ae-tW
(Signed) XE31. au. . �R"`"-QC,
(person in eh e) r c.„69
Address / a. / 6 0 J
,
Person in charge must return th s 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.