Granger, Clinton This`Stub" to be If by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased_ ,-.- `. __—'=w--------------------------
-----
Sex.. -
2. Place of Burial
6. Date and Place of Death... . _-__-____ .....tj--r-
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-----------
I. Cause a,f Death_. ---� - ---
.._.
5. Certified by.- w
--- -- M. D.
6. Undertaker .....
Sold by C.E. HOUGHTALrxG.Law Blank Publisher,Albany Dl. Y.
Form 5%i
" a _ BURIAL PERMIT.
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STATE OF NEW YORE*
•'a.q ..n�L� f l.f�.{
i n 00a S o Name of Town -_ ./
i a«° +' ate,•--'
ai ,M a (Village) and Connty
e °'"'° o �(4�/`,��4 Ca—0--- _(Dated,) � '—, ._19/
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U _ The Certificate of Death having been furnishednn to me, as req ired by the Laws of this State,
Z t e a s C.P. t 1 S /Z-a/��
WI
4l, "a a permission is hereby given for the Burial of
Z a `o w E (City or Tow hip)
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4 " db a § Sex7)(!..GZ Age .__O who died at_. , in the
V __ __ _: on YY. 3. 19 / the cause
� WQ, °'a d' County of_ ..�
t
i 0 i of death being CtA-C714-4-CeQ 1iriC n t_ 4,4j4-1'tace of Burial..__
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aoy ' j-
o IQ G,�•5, °- Undertaker or person t tilt•LQ,�,u,„(,t, _ (Signed by)_ --S.�,
o � c�A � in charge of Burial,
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"a11' ci/2...e.A..., cia.t..4 .
("Ln fi•a Residence �l__�.�/`�C" (OVER) (Official Title)
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BURIAL PERMIT.
Name of Deceased,
L
Person in Charge of Burial Ground or Crema-
tojy 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 l Interment 6lisn -19/Y
Signed
ir-e,
Filed - - 19(le
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 otherwi€^dianosed 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,
ALBANY, N. Y.