Barber, Williiam 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.
..i -Town, Village
%g ered No.
/ _ g
Dist. No..:__t 2 . County . .� �— or City 1- �`- /� -�%UP-./
�� / (If city, i street address)
Name of deceased._... .— -� A' Veteran
(.. (If v ran, give name of War)
/71 Single, married, widowed, �� A G
Sex____ �_. or divorced (write the word ate of th.. ........ .../-_. 12
Age__ _- -�_....Years,.. Mont s ays Birt lace.
i
Cause of-Death _ -.-- t^/
Certificate was signed ..�.. i.' ' z�G.. M.D.
Address.......,-.:-. .-- -_ „ ...�. •
Place of Burial emoval)... . .. .. ..
(If bodyis to be t held, fill t safe lattfr} < <
Cemeery -_ .. .. .r._. -�`--( 1� Date of Burial - 19....
(If body is to be temporarily held, fill In space later)
The Certificate of Death containing the above stated particulars, having been presen ed to me, after careful exami-
nation,,the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for r-_is tion, have recorded it in my Local Rec rd with the above tated Registered
Number, and on the b- - s .f It•r REBY GRANT A PERMIT
to..._ _. y`
y ddres
the ' ~ `. ( to hold temporarily
(Un� or son ving charge of co e) .� Oar,remove, otherwise di ose of [state how)) the body
Dated 190 (Signed) '; ; L i (
Local Registrar
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.
Form VS. 6l. (Rev, 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
er7
--,
Date of - --",-t-t--
, 7
was, -c (4 -.- -2.— 19_
(Interment or,eremation)
.--
/ C ,,,----(
, J 4.-Z - G,r://
Z ... ( e' 7 ' -
(Name of Cemetery, Crematorium, etc.)
1-1(f....... 9
Section_ ,7 Lot No,. e-____!....i_____Grave No._____/__
' - .'-;
-----) ,--:,77-7 C -
(Signed) (P
1,-----e .,,„ , (7
r...,.Z--
erson in Charge)
Address 7C 1 47y/ 2, ,
___41- - "
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 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
vi11 be enforced. Local Registrars are required, under penalty,
,o report violations thereof.