Clapin, Iola Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s: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 CERTIF CATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No. .._.... ..`�_ .....__
Dist NooVki.:��County...::.t.r42.Qkr� 4-L-447k414-4-"/.`.�..�� /
(I!c+ty, give a g¢�E!address)
Name of deceased..S� : G.S.! Veteran VVVVV
�/ /� ) �a Single, marri , widowed, e ( veteran, give name of War)
Seat'r .. 4.:�F.ColorLt�-� or divorced (wnte the word)�� �!�:,�:u'�.G Gam' Date of Death. . .. . . I 19.(L
Age 9 Yeas Mon s. .Days Birthplac `, �•,
Cause of Deaths. ? aw � a-e ..' ,if V,..CP.c..s..:dt, d ,
y V
Certificate was signed by ... . . r. .. ...:. ... . A. .... ... M.D. O
Address /G.A-
Place of Burial (or Removal) .. ..•
(If body is to be orarily J.elt3,ffil t spa later) 7 �..
Cemetery .+�: .. Da of Burial.49.17X42., a 1942
(If body is to be temporarily held,fill In space later)
The Certificate of Death containing the above s 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 Record with the above stated Registered
Num , and on the •'_ hereof I HEREBY GRANT A PERMIT ) ) ,a� o
to , i ti , I. .Q "t.1Gl..cr /X.!. •�,.! . . J..i..
/l �,/
the 0 .. !.. .. .. . ...to hold temp 'ly and the body.
•dertaker or perso Wing charge of rpae) (Inter,re , r o•• ;�se dls�oes f[state ho�/
Dated... .. 19.!?.. `. (Signed)... .. . . -Local •egi,trar
/
Permit is sufficient for the Removal (and Interment or Cremation) o(la body to any part of the State (.abject • 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 �. / 19 Y
(Interment or Cr tion)
4
(NameofCemetery, Crematorium, etc.)
Section Lot No. 7 7 Grave No.
; f , .�
(Sued� �Lti...., .-''`�.
(Person in charge)
Address o'O O a..L( ' r� /�-(�... 42"/
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 OF E.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.