Every, Lena NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
glsk5=' 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.
Registerego..-
Town Villa
Dist. No__Le/ Count C2--0-42-eck---A-4 _. .
,..- If City, give et address)
i
Name of deceased , ...---.<4:...,- Veteran
) (If eteran, give/name of War)
Sitigie,'married, widowed,
• :
Sex.... .___-.. . r'divorced'(write theswoid)..---1,-X.-.. ate of
d1V(
Age. -7 P ..Years...,... nths Days Birthplace.
..
Cause of'Death___.::::j '''' . . A'—e•
Certificate was sign by. --k-Z----
Address... . _
Place of Buri:.4(or Removal)._
(If body is to be poirily held, fill in space! sir3—'-., 6
miy ----- J
Ceete .„..; -.-7-- -.; .-?-. • Z .. of DateBurial - 194*
(if body is to he tempora.rity held, fill in sp ee,Jater) - .,:,/
The Certificate of Death cont Ming the above stated particulars, having been presented o rne, af r careful exami-
nation, the same appearing to be CO u PLETE, CORRECT, AND SATISFACTORY AS 1 ) L IRED BY ,LAW,
I have ccepted the same for - i...Jr on, have reco-t ed it in my Local Record with the above tated-Reg' ered
..,zA
Num.7, and . the' basis therpifill'-;t: BY • ; T A PERM 7/0 4.
to ...".. ._ - . ..,
...,, ,,, , ____
612,.-7 V , .
lfr 1 ' (Nam 1"1"-1.. AP' .ddre
ss
the.......:11... - . - ---• o hold-o-' pora ' uLL.x.vw...a.. . - ...th body'
_ .
(Un itker or p on ha3g_shargeo6f cri," '(Utter,r ove,or otherw tap s I)
Dated .. ID9 (Signed) - _
1 Local Registrar
This"-rrnit is ricient for the Removal (and Interment or Cremation) of a body to any part of the State (subject tZ/Cal
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is required.
Form VS.h6l.•Filet,. 6/63) (3A2-323)
r;1v LOttEM N 1. Ur SEA TON Ott PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS QR
CREMATIONS ARE MADE
Date of was _19_
(Interment or Cremation)
(Name of Cemetery,Crematorium, etc.)
Section____ Lot No. Grave No.___ __
i n(S g ed) f
(Person in Charge)
Address
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
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.