Sollahub, Millick This"Stub- to be kept by.person issuing Permit,
BURIAL PERMIT
1: 1 anae of 13ececased
g -.._
q. Place a,f Burin .L
g. Date and Place of Death.._. -- -------
fit` .... -....
.�. Cause of Z7eatla--------------- `.`k. - _
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6. C`crtifaed' . .�
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6. Undertaker..---.1
Sold by C, E. Hour.HTALIN..Lax Blank Pablisber.AtlzanY §;
Form 5%
` STATE OF NEW YORE.
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'ti s�a L
BURIAL PERMIT.
...Q K�. m A O Name of Town i G-'C.t/y�_D_].. .C.R.4��' -- Lf� - -` '
p m ate' I(Village) and County 1 lQ
as a 7�
e o --- _(Dated,) -Q�-e t% • R 19/ 1f
• U _ v v The Certificate of Death having been furnished to me, as required by the Laws of this State,
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44
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'" u�� � permission is hereby given for the Burial of _ _._ ��V//
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/Z
y e c v 3E
(City or Tow ship)
`I LV 4 U n /
�b�
Sex_r"-a-ex Age (9 wha died at in the
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>" ll '' �- 19 / the caz�se
W SQ County of (/�/_G1.. �L.�/ _ on :4Z`,9
(� m a; of death being 7�l�•`-w■�•� Yen.�i e -�.�s�Lt,�sp�ace of Burial.._ 9Li(n�'.x Cs -S�frtl
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�Q a�,� Undertaker or person ) � ���.o (Signed by)____ _ •
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o " a in charge of Burial, C
va / �7/- 2
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q v) II•a Residence___ Y.t.6 C�xt. V (OVER) (Official Title)
41
'RIAL PERMIT.
lame of Deceased,
Person in Charge of Burial Ground or Crema-
tory must fill out this part, and file the same with
the Registrar of Health, within seven days after
the disposition of the body.
Date of Interment _ -- 19/
Cremation
Signed-___12
. . .__
_. - 4,
Filed e-----
Registrar of the .7( „
of N. Y.
NOTE—This Permit is only to be issued for a Burial within the County where
the Death takes place. Cemetery Keeper,etc., must fill out according to above
Certificate. In case no Person is in Charge of Burial Ground,the Undertaker must
fill out that part on the other side of this Permit.
Every Cemetery and Crematory are required by Law to keep a Record of all Bodies
interred or otherwi=e di..used of on the Premises under their charge.
BURIAL PERMIT BOOKS, TRANSIT PERMITS FOR CORPSE ON RAILROADS, REGISTER
BOOKS FOR CEMETERY TO RECORC BURIALS AS REQUIRED BY LAW ARE PUBLISHED
AND SOLO BY
CHAS.E. HOUGHTALING,
LAW BLANK PUBLISHER,