Sullivan, Humphry D This"Stub" to be kept by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased _-.
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2. Place of Burial__: �-��-
S. Date and.Place of Death_--------------------�___-----------
----_--------------
Cause of Death_.. -. .. .------- ---------------
-.
6. Certified by...." ..... .....
----- - ------------ ---- ------------- M. D.
6. Undertaker
Sold by C. E. AOUGIITALING,Law Blank Publisher,Albany, N. Y.
Form 53
q STATE; OF NEW PORK.
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BURIAL PERM IT..
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rr U d 5. The Certificate of Death having been furnished to me, as requ red by the Laws of this Stale,
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t. ��s o. permts ton is hereby given for the Burial of.__ �,..y _ __�___ __ '-2.
s T. a o°'a E��c o / � (City r TownahiD) -
• v Y Fi Sex f Age rZ- who died at__..._ , in the
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W T o a t County of______ �1�f^ on a. _ _ _ 2.7 19/J the cause
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Q i ; +' of death being �..j„ v o rtr e.a. - �+�-�.. lace of Burtal.__ l'ln.�s.u� .C.
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y aG �'5 y Undertaker or person (Sid ned by) _ _
o 'zi l';v :2 in charge of Burial, / j
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'a0 Residence.. ..
* Q v) v'a - -- - - (OVER) (Official Title)
BURIAL PERMIT.
Name of Deceased,
6
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
Cremation __ n -191 `1
Signed-it- Tt',-c� ' _ '4
. 1.e. Js _
Filed---- ✓^ 19�
gistrar of the
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 otherwirn lisnnsed of on the Premises under their charge.
BURIAL PERMIT BOOKS, TRANSIT PERMITS FOR CORPSE ON RAILROADS, REGISTER
BOOKS FOR CEMETERY TO RECORD BURIALS AS REQUIRED BY LAW ARE PUBLISHED
AND SOLD BY
CHAS.E. HOUGHTALING,
LAW BLANK PUBLISHER,
ALBANY,N. Y.