Hoag, Rosalie 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Vill egist@red No
�( / ountLO cit/►�Ali'L/ or City... ?e
fist. No. . •
([f city, giv street2 res
pe
lame of deceasedA...v.......J,L. . Ve
teran E,!
/ (If veteran, give name of War)
Single, married, wid ed, (((
k/
;ex .9-- / or divorced (write the wor Date of Death 6. 02/ 19 ...� ..)
kge ( ear •
Mont-s ...._ Da s - Birthplace..... • .
2ause of Death .. �"-
2ertificate was`signed b . . . M.D.
Address 1
'lace of Burial (or- emoval ...........
If body is [o a emporarr - he d space ter
;1.)
Date of Burial 7 v2. . ` 19..,20)
If body is to he tempor rily e , fill in space later)
'he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
ame a earing to be COMPLETE, CORRECT, AND SATISFACTORY A REQUIRED BY LAW, I have accepted the same for registra-
ion, h e recorded it in my Local Record wit the above stated Re i tered Number, on t basis thereof I HEREBY GRANT A
'ER\I I (Na. ^^ , t '
me }•adr ss C ;
he to hold temporarily arkl ���//// the body
( n erta•er or pets n h ing charge of co se) rater, remo , or er Ise spose of (state how))
'ated ( , ;22-.{ 19 ) (Signed) -
s Local istrar
This<Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of th tate (subject to local cemetery or
Cher regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62 is required.
'ORM VS. 81. (REV. 6/631 (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN UHAxtzt;
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of lx ".-K- was N 19 7 k
(Interment or Cremation)
yy /
(Name of Cemetery, Crematorium, etc
Section Lot No. - Grave No.
(Signed) < ��
(Per on in harge)
pyf •
Address
/ck80/
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 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 required, under
penalty, to report violations thereof.