Thomas, Jean form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTI ATE OF
DEATH, LEGIBLY WR DURABLE BLACK INK. Town Registered No—.. _ .-
Dist. No ..Coun ......ge_
—
,�� (If city,give stree ddresa)
Name of ceased ..� .:� . --rill)VI if— -. ••• ... Veteran
Single, married, widowed, veteran, give name of Wsr)
J` g
Sex. .Coloie-' or divorced (write the word) w Date o th.. . . ...... . . ... c.19
Age 72...--.Yyars Month. .....Daays Birthplace......Cause ofeath.. `
Certificate was signed by 4'. M.D.
Address......1.Q. ...1� d�j • •,.. ,..
Place of Burial (or Removal) !=t,c .
(If body is toqt���porarily held,fill in c later) ,//
Cemetery...Crl •L-. Date of Burial l-- 19.4z.7 -
(If body is to be temporarily held,'fill in space later)
The Certificate of Death containing the above ated 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 ord with the a ve stated Registered
Number, and on the_basislhereof I HE EB GRANT/ A PERMIT / �� �/
to ... (N ( )
thew L,/�� �( .e. J .ex�r� f.�t1 ✓✓✓ to hold temporarily and -,•.' the ody.
(R(ndertaker or person having charge of 9orpae) / (Inter,rer ove,Q .thej se disnoae o tate how])
Dated..r(sC{- .c..... ..7 19.i .4/ (Signed) .• . iz� 0-�
- _ Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to 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 SEX`1UN OR PERSON IN CHARGE OF
PRINISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date 19 / 9
(Interment
V L '
Name or Cemetery, Crematorium, etc.)
Section t N1 0. Grave No.
(Si gzled) ��f� 67,
(Person in charge)
Address C ' 0 e=
J f
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.