Swan, Franklin Form va IL 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town , Registered No.._..1...),...C._......__
t Village /. "��c 'l�Dist. No. County...` f � 1�'� or City �-
r - (If city, give street address)
Name of deceased --.Y�./..t:".ae4-7--/flG �.....`l� -u- 'lJ Veteran -74-c
^fin / Single, married, widowed, (If.veteran. give name of wax)
Sex X 1'! Color.../. or divorced (wnte the word Date of p th:...-.ems--- /-5--19..4 ,/
Age 7/ Year oath Days Birthplace.. '.? ... y..,
Cause of Death ?'tea:: < Z2. .
Certificate was signed b ..-7.r M.D.
Address ?.. . � .i 4_2)
Place of Bu ' r Removal)............. .74::??. '.. .. , 'Y
(If body is to b orarily hel fill in spar"L^^ater) -
Cemetery.... '..�/ ....J G,4' 1 . Date of Burial i �' �i..�.. ..19. .
(If body is to be temporarily held,fill 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 ac ted the same for registration, have recorded it in my Local Record with the above stated Registered
Noumber onth�e basis/thereofI HERBY GRANT A PERMITj� � .
v ) 1 -441 -.
/ C - '� (Address
the .2' to hold temporaidlp and the body
(IIndee ker or person rasing charge pr c rose) ". (In more. ,g4et ise dispose of[slats how])
Dated .Gf'�.;La err.1.�..../.. 19..6..1. (Signed) --
Local Registrar
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 ` .�7 .r,�'� w ,/f x 2 %l is
/1 (Interment or Cr(SI
emation)
/ C
(i(ase of Cemetery, Crematorium, etc.) /
Section .-"t om"' - Lot No.1 _Grave No. �_
74;_
(Signed) ,/ %2Z' �1 .. V� CJOr-1../1/6,40
(Person In charge)
Address /--7k--(17-4-4!.--,� -t--- -JCL'
Person in charge trust 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.