Barber, Celia Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit cart 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 Village— -
Dist. No • County �� '� or City (� �e- 7-Z-�
(If city,gtv treet address)
Name of deceased LrC sr-ci.l 5.,. ..B.C.t.. ,r Veteran --7'
) Single, Mai t fed OW Wftted, „ (If veteran, give name of War)
Sex Color....�.t or divorced (waste the word). .... ate of Death.. . 19 g�
Age ' • Years Months Days ,g y Birthplace.... �,. 0. x- .,›.j..
y____
Cause of Death ,,e .. .. .L.A. ..
Certificate was signed by.l...d..1/2.,... .. .. y— M.D.
Address `_.,.(...:.i• .� �:z.%C 8.
Place of Burial (or Removal).... �. + /"Z -Zs.1'" e„.k. r.�.� y... -
(If body is to be temporarily held,fill irk pace later) . ° ,/\
Cemetery l•-. :.:f.''-- e..C.-Iry Date of Burial..... L 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 �]� /IN
to 1(.,.....i...r....l,. ,.. C.. ..a.n. �1�! `` �� "!//( me) ! ` (Address) l
the......:...:..:. 4.. .. ,, t..a. i, to hold temporarily and.... . the body.
(IIn erlaker or person having charge of corpse) n r,remove,or otherwise dls se of[state how])
Dated.. ..../..2 19..;i..;0(--_ (Signed).. .\....
�2���~tNLacsl R
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any part of the (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case alTransit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CITATIONS
ARE MADE
Date o 19
(Inter..t or re Rion)
r ��t
(Name Of Cem�y, e at rium, etc.)
Section !7 7 Lot Noi2411f2V5Grave No. _,
A
(Signed) �` -4/el
(Person in charge)
Address Y L[ <5 4
Person in charge must return this Permit to
the Registrar of his District within SEVEN CO 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.