Hart, Harry NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. .
Register d No.
Town, Village
Dist. No -ge/ County _ditt,L/x- or City
If city, give street address)
Name of deceased 4 Veteran
(If veteran, 'ye name of War)
Ma_i_9, Sin , married,widowed, /�Sexor divorced (write the word) O Q .- Date o Death 19.0-
Age b-_13 Years Months D Birthplace
Cause of Death ---- S � � � -rn ,
Certificate was signed by -C�1-6-.-/- M.D.
Address kee.--"L_
F-�� ', aPlace of Burial (or Removal) J __ .,
(If body is to b ora ' d fil in space later) - _
Cemetery__ Date of Burial v� /✓ 19
(If body is to be temporarily h (1, fill in space later)
The CERTIFICATE OF ATH containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded it i my Local Record with a above stated Re - tered Number, and o the basis thereof I HERE-
BY GR A P+RMIT
tO . v ,(-14-.-a41—"+\ -d'
K y c,.4_,Z _,Z : - t__&
ame Add ess)
the to hold temporarily and ��(� the 2
(Unlertaker or pe on 7ing charge of corpse (Inter, remove, or otherwise dispose of (state how))
Dated /__ 19 (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod t ny path ject to local
cemetery or other regulations),unless removal is by common carrier, in which case a T it Permit (VS N . 62) is required.
FORM VS.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was / ) 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.) ,
Section A • 7 Lot No. /0e-P Grave No. _: _
(Signed) d .(C.- .2a':_.
(Pe son 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) DAY
with the Registrar of District in which cemetery is locate
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of perm
are liable to a penalty of NOT LESS THAN FIVE DOL ,
LARS NOR MORE THAN FIFTY DOLLARS FOR TH ..
FIRST OFFENSE. The law will be enforced. Local Regis- ';
trars are required, under penalty, to report violations thereof.