Hendryx, Eliza i
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STATE OP NEW TccreK0
F.
Forms.
.g- BURIAL PERMIT .
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Name of Town
(ViRa�el and County.
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111(a .L4.— e—.0 (Dated,).... ... 19
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
is hereby given for the Burial of V ea4,,. ,.�,- a 2
o
c (City o Township.) g ,T
who died at.... , in the County of. ..
y
�.- ,on . 19p,.3 the cause o death being. i ..
g , Place of Burial V.,R-.3e3 i..A
I y Undertaker or person 1�
;, in charge of Burial, ""� ' •' (Signed by) Yn ' . V i
i /Residence 7
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(OSda)title.)
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BURIAL PERMIT.
Name of Deceased,
•••••
Date of Death,
Cause of Death,
In the Town (Village) City of
County of
NOTE.—This permit is only to be issued for a
burial within the county where the death takes
place, and is to be kept by the cemetery keeper
where the body is buried. It is to be issued on
the filing of a death certificate,certified to as re-
quired by Sec. 23 of Chapter 661, Laws of 1893,
Nore,—Burial Permits, and all Blanks are to
be procured of Town and Village Clerks and
Boards of Health, for the Registry of Births,
Marriages, Deaths and Burials.