Rhodes, Foster Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tz 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 DURABLE BLACK INK Registered No—......... .. .. .__ .
Dist. No 3301 County ONOND'AGA , " City SYRACUSE
(If ety, glee street address)
Name of deceased I • CR .w-0- sa_, Veteran
Single, married, widowed, (If veteran. avee na a of War)
Sex or divorced (wnte the wor�X- Date of Death. , ' /" 19 67
Age 6 / Years Months Days Birthplace c%a-- "..:?
Cause of Death-. :rt ��4-�•
Certificate was signed by. (a.. (..,:�- ' M.D.
Address `_7
Place of Burial (or Remov ) , 2 �—
(If body is to be tempo a ly beld,till 1n apace 1 )
Cemetery .. .... .. Date of Burial 9 " 19 ',2
(If body is to be temporarily held,till in opace 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 accepted the sanne for registration, have recorded it in my Local Record with the above stated Registered
Nu , and on the basis thereof I HEREBY GRANT PERMIT
to. Di- o r _
( ) dY�----r �._..` �- (eves ...."..
Na )
the of temporarily and t body.
(Undertaker or person having charge of corpse) ter,re ve,or otherwise di s+w (etat',how])
Dated .r,,zlr- 19 J (Signed)
D UTYLocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the state (tsubject to lou
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
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of // ss, was__ \,Cc f-/iTG'' 19 (' ry
(Interment o
(ZC
(Na.. of Cemetery, Crematorium, etI )
/
Section (: Lot No. Grave No. /- .
(Signed) z ., C2
(Person in charge)
Address ! f C'L•
i// �/
Person in charge must return this Permit'
the Registrar of his District within SEVEN (7) DAYS
frau above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE 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.