Hammer, Frederick Form VS.s><. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN D RABLE BLACK INK Town Registered No._.__..1..
(7^ , Village ' • ,
Dist. No2t'.7.Lt...County..._ ... .- or City u� 4)-7 ,.,sa,, ,_ ,,,...
2 1 (If lty, give street add es)
Name of deceased ,� Veteran ----
l Single, married, widowed, (If veteran, ive name of War) '
%� . .... ... 9..1
Sex)/f- �, Color..��.' or divorced (write the word).d�/� . ... Date of eath. . ...
Age....f. , Years Mo s.. .)..Days Birthplace... . '
Cause of Death .6 - .. :.. `-� �-- t i
Certificate was signed by... .. ?... M.D.
Address ,,ia ..
Place of Buri�(or Removal) e�-xc� c'. ....'
(If body is to be porarily 1 fill in s ace later)
Cemetery. / ate of Burial..77-4-r----). ,...r 19.
(If body is to e 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 pted the same for registration, have recorded it in my Local Record with the above stated Registered
Num /�'' the basis ereof I EREB GRANT A PERMIT
to •./ktt x .--. .. ,.. . ....
(Name) .
the .�/? ~�G.e:. .-,�-"' to hold temporarily .t'..."( the body.
rtak r non ng charge oerpae) f (Inter,remove,br otherwise dis�orte of[state how])
. . . �.. 19.4.S (Signed) .�`
Dated... Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'Rat. (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 SEXTON OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREIdATIONS
ARE MADE
Da was 19 4�
(Interment o.
(Name of Cemetery; Crematorium, etc.).-
Section Lot No. Grave 146,,
(Person in charge)
Address (G'/,f t'
Person in charge must return this Per i 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 AJUVE 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.