Vandenburgh, Flora NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
IC. 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ��
Registered No.
Town, Villa
Dist. No.S u l y_ or Cites._ _ .
If city 've>street a re
Name of d ased Veteran //( G/
(If veteran, give name of War)
Single,married,widowed,
Sex . _ __ ._ or divorced (write the word) __,/. Date reath —C-c2/ 19.
Age _.. o__...._ ea s - Mo hs Days Birthplace
Ca se of Death
Certificate was signed by _-- __ _ M.D.
-29,
Address
Place of Bur' (or Re oval)
(If body is to be a poraril 1, fill a later) ) e
'Cemete __ - / - A_ ,Li/L Date of Burial h2,_c 19__-,7.2
(If body is o be empor it he d„ ill in space later)
The CERTIFICATE F DEA H containing the above stated particulars, having been presented to me, after careful examination,
the sa appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for reg s ation, have recorded it in my Loc Record with the above sta Registere umber, and on the basis thereof I HERE-
BY G NT 1 PERMITJrgeofc
`
t0 - --- - - -- (Addres
the to hold temporarily an body
r es h or se ( remove, or wise ose o st ho ))
Dated al-* 19/1._ (Signed) �G.
- - -- --y--- ---- --- - -
/ Loca Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o 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. 61. (REV. 6/63) (6A2.130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 7t f S was Z.- 1922.
(Interment or Cremation)
t c fi A h 1 cis
(Name of Cemetery, Crematorium, etc.)
10
Section .5 A ' Lot No. L 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
UNDERTAKER 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 District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.