Aiken, Chester NEW YORK STATE DEPARTMENT
OFFICIAL BURIAL (OR REMOVAL) PERMIT
HEALTH
EF' 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No�`y ¢ County 2-0.4v „,- Town, Village Registered No
or City
r -��
Name of de
ceased
(I city, give street address)
4. Veteran .............................�n Single, married, widowed, -
ex.. Z (1 veteran, give name of War)
,EE/�� or divorced (write the word ...`_�,
YearsMonths ) ,&z -..--.Date of Death 7 '
Age of-Death ......•.....___.. Days 19.
""' Birthplace
Certificate was i �.•---�%z- .................. ...........................................
CauAddress _•-- ...... ..........
Place of Burial (or Removal) -
(If body is to be temporarily held, fill in space later' "•" " M D
Cemetery......................................temhdpace.lat ) ,,pp '' ---- l(If body is to he temporarily held, fill in space later) `�rs+:.! , •• --,•••'•••.-•••--.•-••-•.------•'---�
ate of Burial �/
The Certificate of Death containing the above stated particulars, havingbeen presenter c careful
1 ami
nation,,the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS
I have accepted the same for registration, have recorded itin my Local Re d to me, after careful exami-
nation,., and on th ,- is reof I HEREBY GRANT A PERMIT REQUIRED RegisteredBY LAW,
to with the above stated
( ame) ...
the
to hold ( ddress)
(Und aker or person having charge of corpse).....................................
"" temporarily and
:? 19. f1 (Itl�remove, or othee body
. ................ -'e ispose of (statehow])
- (Signed)...-----•--•-•---------L-------`J'`?�-^-:'----- ----..............
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an
cemetery or other sufficient unless remva is byLocal Registrarrof "" -
ce toVS. y61. rot(Rev, err regulations),
common carrier, in which case a Transit Permit the StateNo (subject ise i local
(VSNo, B;1) is required,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
17
Date of w 19 /
(Interment . remotion)
(Name of Cemetery, Crematorium, etc.)
/� /f
Section "' Lot No. Grave No. - -_
(Signed m- -+ 1/4
(Person in Charge)
A ( •
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN s'7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words 'No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict in which cemetery is locaied.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable tt>
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 required, under penalty,
to report violations thereof.