Lord, Pheobe s _ _
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Form 5%
ST-ATE OF NEW TORE.
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BURIAL PERMIT.
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* (Dated, 94-4....,...4-e___./L • 19 /L.
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The Certificate of Death having been furnished to me, as quired by the Laws of this Stale,
permission is hereby given for the Burial ef_C?14-11.4., C"?VI---4-- pteftri
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Sex44,4-utaa-Age La who died at ... :,
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2 n g County of _ /t_te 19 /4;the cause Ai
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0 • :41;•:-; ±? of death being.e.......,...,..1,4 . . or
Place of Burial C2.0...44.A2
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°— Undertaker or person } ° s.,..,,..e, (Sig-ned by)_131 __
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in charge of Burial, e-
4 ' • ',4!! -11:4 Residence g...c...u-c-42 Atile4 n , -- ,
,) (OVER) (Official Title)*
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BURIAL PERMIT
Name o f 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 /y
Signed_Sfi
Filed " 2' 1wp
Registrar of the-
of L-..-1.'t'te' N. Y.
NOTE—This Permit is only to be issued for a Burial vLhin 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,
AIRANY N Y
This"Stub" to be kept by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased-. _ -----------
— .._-------_�ge r----- -�-..__.y
2. Place of Burial----" ---Q-- ,.------. ------
8. Date and Place of Death. --------
.__.__._/
4. Cause of Death.... - --
----- ----
6. Certified by.... ....
tLI. D.
6. Undertaker----T -.. � -- --- ------
Sold by C. E. HOUGHTALING,Law Blank Publisher,Albany, N. Y.