Codner, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 C RTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
d .
Town, Villa ZAegist C,..)
Dist. No.SC‘) Onty Town,
or City
4:...,,y
- -
Name of cease. ‘,.„--i .. 6- 2/ 1111-
Veteran(lf city, give"str e a dr s)
(If veteran, give name of War)
Single, married, widowed, Zu
n ,
Sex 41 v-,-- or divorced (write the word . . . . Date of Dea r — 3 19 26
• / ,
Age , 7)....... Y r Days Birthplace
,Y.
,
Cau e of 15eath
Certificate was signed by M.D.
Addre
,.../
,- ." •
Place of Buri (or Reipov .
V t .
(If body is to ,e t,xrcaZy e cil i sp c ater5 4A,
Cemetery -- -
Date of Burial _ , 19(If body body is to he temporarily he d, fi in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS R QUIRED BY LAW, I have accepted the same for registra-
thereof I HEREBY
tion, • e recorded it ' y Local Record„Fith the above stated Registere umber, and the sis GRANT A
PE 7T /.
to .4"---
,..4. Ares
j
the to hold temporarily and the body
,
(Un erta ecrpers a ng charge of cTe) (Int remov , or otherwise dispose of (state how))
Dated 19 / (Signed)
• oc441/14%
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (su ject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
Poitm VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of a 19/ 6"
(Interment or
•
(Name of Cemetery tc )
/-61/4 Z61)4—
Section /9 Lot No./''i/Grave No. /
(Signed)
(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 UNDIr-
TAKER MUST SIGN ABOVE STATEMENT, write across tP
face of the Permit the words "No ',person in charge," a d
FILE PERMIT WITHIN THREE (3) PAYS with the Regis
of District in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKER
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 Registtars are required, under
penalty, to report violations thereof.