Bovee, Baby Boy This"Stub" to be kept by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased---..6 --(-
----—--------------—------------------------------------------------
Sex.....:)!:�.......
2. Place qj B-urial.-----t+
f�-------------
8. Date and Place of Death
------------------------------- ------- ------- ------- ------
Cause of Death 4(
5. Certified by-A . ............... t..............................
.............•-------- ----------—.....M. D.
6. Undertaker.... ------...............
Sold by C. E. HOUGHTALING,Law Blank Publisher,Albany,N. Y.
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i - c" STATEK/F NEW '✓ • Form Sidi
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`ym - BURIAL. PERMIT.
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x40 4 s a; L/-1'- ` ( i _____.__(Dated,) £ 19/!.f
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r r, The Certificate of Death having been furnished to me, as required by the Laws of this State,
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Zt u a Q permission is hereby given for the Burial of rQZ1' .. 6 C 15,4. o (City or Township)
a mb § Sex_ � Age.�1.l. -i% 4 who died at 1 — 'n` , in the
Wfh *2n c4 County of - __ on..._-_____-_ \_ / 19 /ff the cause
0 i v .. of death being__�}j%� Place of B rial.._lei'Qil.rt ,.�.LA GT�4
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a„'� n- Undertaker or person S. (Signed by)...." �f .222:zeoge.
o 'ct "^°` co in charge of Burial
--- -- -- - ------- -
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Grfel -.aRce ..� ."q .. v LovaR)
(Official Title)
9
s
BURIAL PERMIT.
Name of Deceased,
`., . 4
Petit in Charge of Burial Ge hd 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 __19
Signed
Filed J 7-_-- 1 9/}
Registrar of the
of 'L t >R" '' 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 otherwise di.nosed 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 SOLO BY
CHAS.E. HOUGHTALING,
LAW BLANK PUBLISHER,
AlRAR9 R V