Chadwick, Howard This"Stub" to be kept by person issuing Permit.
BURIALPERMIT
1. Name of Deceased_-- ----------------
i ----------------------
-----------
------- Age,------ -- ---------------
2. Place of Burial---- --- ----------
Date and Race of Death-2
-------------—------- ----------
4. Cause of Death
5. Certified by.....Qn-1,�- -
.........M. D.
---------------
6. Undertaker... ..... ...........
P: Form 5%
d STATE � ip\ e I
aN. BURIAL PERMIT.
-El('� co
0°�°v o Name of Town _l ,r �)
a
—a T !(Village) and County I A --.I
x .a' o V�"420:�Q.AAG_ ___(Dated,) Yn" ''. 19/
lf.OS
U v @. 2 The Certificate of Death having been furnished to me, as required by the Laws of this State,
"" �r:i; � permission is hereby given for the Burial of. .�L___Q't�`��-Gf �a.
Z 1 �a o
O �— (City or Towns D)
Ch "Ili E Sex Y -Age 3 0 who died at in the
a '
W� Mga c4 County of___ _n_ on !1 19 I9 the cause
o +' ofdeath beingi o YL�-o�-
Z -e -- - -- Place ofBur:al__.. � 44•2 ,.G _�
A,..f Undertaker or person t " J (Signedy
o 'ti - 2 in charge of Burial,
N ya � � 1
Z tt a Residence. �t'jt�-!.mo o-Q,Qeo . 7`1 (OVER) 2(Official Title)
BURIAL PERMIT.
Name 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
Cremation —_______________ 19
Signed
Filed 19
Registrar 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 otherwise disposed 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.