Delong, Daniel :_l .1 "
This , tub`" to be kept by person issuing Permit.
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BURIAL PERMIT
1. Name of Deceased-- -,_ ----- '-_-_ ------
- - ------ --
Sex---- -- ---- -----_... Age, 4� .
Q. Place of Burial---
S. Date and Place of Death
4. Cause of Death. °°:. �
5. Certified by.......
•------------------ ------------------ ---._H. D.
6. Undertaker. --- . . . --- - -• .►�.
Sold by C. E. HOUGHTALINo,Law Blank Publisher,Alb ny, N. Y.
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AForm Ski
o v STATE OF 1 TORE.
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aN _ BURIAL PERMIT.
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40 (' ;'.c ate-. l Name of Town lk�
▪ . o a-, l(Village) and County(—� -
x kr4t-------- - (Dated,).
i 19 /
74
' U v 2 The Certificate of Death having teen furnished to me, a quired by th Laws of this Slate,
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t u�� � permission is hereby given for the Burial of.__��s�ri�s,;� �`• . �_ t
s „..9, o (City or Tow ea6iv)
fa —M mb Y co Sex_YYS. Age 19 14.• •� --- who died of-_ _. - - in the
w IA
°S a g County of JtK_._ h ,(6di,� on- t 3 19/ the cause
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0 o E ofdeath being C: yyt.
Z y ' :aft... Place of Burial____ it,e,�,oa®iltf�iC1 � �
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°a'� Undertaker or persont )f (Signed b ,,,_ �s _
o :ita as in charge of Burial,
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I ^� •� --5 Residence dis .�,j��
Q V1 ..3 fovea) / (Official Tit e)
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3U R[AL 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 /./wvi_.-1
Cremation__ ___19/q
Signed d7Y.i01�
Filed r -- /459 1 a''>'
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 otherwie di<nnsed 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,