Mason, Olney Form VS.ea. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
cr 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.. .. _._....._-
Village-
Dist No SG C I County..._. u. e— or C / U;'�-
Qf cit>, give street address)
Name of deceased .. . . .. .. � � -� Veteran
Si. le, married, widowed, (If veteran, slue name of War)
Sex.. Color.... or divorced (wnte the word) Gbh!? Date of Death - I 19.6-../
Age -2 7 Years Months ,.- , ays .Birthplace
Cause of Death - .... .. ..
Certificate was signed by .4( . ??. 7.:�!.. R M.D.
Address �� ... ... ; '?,,.C, '
Place of Burial (or Removal) ..!.,l. in e .,ta-c-t�'r
(If body is to be temporarily held,MI ins ce ater) _ , /
Cemetery a.. n. .....d.e,t Date of Burial rc - - — 19 G ---
(If body is to be temporarily held,f111 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, and on the basthereof I HEREB GRANT A PERMIT
to 4-1 :::c .... ... «--e-z .:--.
Na ) dd as)
the to hold temporarily and the body.
(Undertake,or person acing charge gr co ) (Inter a ose,or otherwise disnose of Estate bow])
Dated ,,; .�ti L 19...b. (Signed) _ .'....> ...,.:.:i: ...
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.
ENDORS1MENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Da was 19 4 1/
(Interment or Cr
, c.
.... e..7. ..,,, 47. .
I'
// t
(Name of Cemetery, Crematorium, etc.)
Section- 7 Lot No.7.-245 Grave No. r
:7.
(Signed) 4,vc, 14(-ti• VI;21,e714(1
(Person in charge)
Address /O�/ :Z,-^�- Vk— _'�le
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 wards
"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.