Baldwin, Charles • Form 5%i
a STATE OF NEW IT RK.
••
"�
� BURIAL PERMIT.
�om
Ii
o J Name of Town _---• .. ... '�"T j(Village) and Connty 1 - -- --- --
•4. 4 s a a __ �_.__(Dated,) yh�ck Y 19ly
50 U _ d . 2 The Certificate of Death having been furnished to me, as requiredfir eq by the Laws of this Slate,
i r s a permission is hereby given for the Burial of. r
. o=3 (City or Townshiy
til
ua^ o
0 g Sex4.�iS..___ Age died at , in the
W � 1L. who
{it M2'Q = Counly of 1Mrs.l.e4a.--- on..._ . _GA-L'. Li' 19 ! the cause
0 ; a' of death beingd... ii[a,,C,4Ac_Place of Burial__Y- att--'t tc+4-1' 1
4 z L apn m
� W o,i a Undertaker or persont (Signed by)_�_�7. (� s.1
7**r o 'tt t'a v -f in charge of Burial, ) ,p�- —
2 n v) N"13 Residence (OVER) (Official Title) _
3T '�I 3
N•J JJ{
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_ 2 2_19
Signed t;) (4 O
Filed �'`''� '( 7 1 9
Registrar of the
of ` ..+ - r N. Yr.
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<e dinosed 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,
RICRNV U v
This"Stub" to be kept by person issuing Permit. '
BURIAL PERMIT
1. Name of Deceased..." -`- -----------------------
r
L ------------- ------------------------
Sex.. _.-... Age------
2. Place of Burial - -------------
S. Date and Place of Dealh.------------------.-._.-__-------------__.
a�. - ..........--•--
. Cause of eath..1..
- --- ----- -.
6. Certified by. tam........—...._....
----- ------- -- ..M. D.
6. Undertaker - -r .----.
Sold by C. E. HOUGHTALING,Law Blank Pub lisber,Albany, N. Y.