Batease, Darell Form Va.si. 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 CERTWNATE OF
DEATH, LEGIBLYE WRITTEN IN DURABLE BLACK INK. Town _ Registered No._._/_...._........_
Dist. No..3.L.Q!.l...County..._.-...��.f. ..41l t...r .. or Village
'-/-'i,^-v/ ..yZ 4—
��Lam- (If city, give street address)
Name of deceased c i�r..... l Veteran
jj� Single, married, widowed, (If veteran. give name of War)
Secc ...Color - -Y or divorced (write the word) k Date of Death ... —u' - / 19. .'ri
Age i Years Months Days Birthplace
Cause of Death ~7'91 . c..t i?r
n
Certificate was signed by r 'is rt `�'-�-.-� M.D.
.--
Address . ... 2 .- - - .:.
Place of Burial (or Removal) ,--9`63. �
(If body 1s to be temporarily held,IIli,in space iat r). .
Cemetery '.. ::....caz. . Ix..i. €- .z -- ,/ .Date of Burial......, '-/J - /9 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbers and on the basis thereof I HEREBY GRANT A PERMIT
to i•::t '-- ` .... :' .-
Name) (Address)
the . . to hold temporarily and the body.
(Undertaker or person having charge of)corpoe) (Inter, ve,or oth swiss dijnose of[state how])
Dated .„q-..(.i // 19.6,V (Signed) Loc al Registrarefr—
u
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 SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTUITS OR CREMATIONS
ARE MADE
Date o `-'J�/��^� ./ was �J`� / 19
(Interment o
yr (Name ofetery, Crematorium, etc.)
Section Lot No. / `' Grave No._�
(Signed)
(Person in charge)
Addl�esS �/J L. f t r �Cl
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.