Eggleston Jr., Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
/0
I a ��J Town, Vill e t� I Re ste d N
Dist. No_ County 3 c�r+ "" o City ' ^'i'e,c agd"'e-
//�<�j 841
� (If city, give scree address)
Name of deceased �Or' vw f/ V‘e416"1';.)2, r. Veteran
i (If v eran, 've name of War)
�')') J Single, married, widowed, , /
Sex u'( A-6" or divorced (write the word) 6 n �� Date of R /h. f P! ��/ 19..b.
f
Age Years. / Months Days V Birth lace...j .. ..�? `9-4..t...
Cause of-Death � en v n ' 14 °ac � 41,,,'��,r ve 4 / U
Certificate was signed by ' 24 '4 • t°1"'t^' f r t M.D.
Address ,.� ' n ,
9'1
Place of Burial (or Re oval) - u:. ;.�.. f;�e� ras 'Y . ) /(If body is to be temporarily�}�, fill jq spy er_) Cam` 2vF.
Q 0 L `Cemetery !.-........ t7�r^'�,, Date of Burial oG f-- 19r/✓(If'body is to be temporarily held, fill ins ace 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 a,cepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number an the basis thereo I HEREV GRAB',6�ERMIT�r� f /i`, ave
to. l.:4, t'n a-n. 7' our, src i '/(/G c t �i
the /�7i` e�l'211 to hold temporarily id 'h - the body d,
(Undert er or rson havin ch rge of co s r remove, or°therwi�e�dispose of ow]
Dated ,,� t9 ' 19. (Signed) C.�%✓�/
r-•' Local Registrar -?)./ . S'a
This Perm t is sufficient for the Removal (and Interment or Cremation) of a bo y o any part of the • . ,- ubject to local
cemetery or other regulations), unless removal is by common carrier, in which case Transit Permit (VS No, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
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Date o£-"t"''/ 2-'y was ._ •__ ��__19_G_S —
(Interment or Crematio
(Name24—
Cemetery, Crematorium, etc.)
Section___._ Lot Nio. I� Grave No.
.)(Signed) t'`
(Person in C ree)--
Address6 --e"tt--41`
I
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 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 locatefl.
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SEXTONS,FUNERAL DOtECTORS 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 required, under penalty,
to report violations thereof.