Fox, Silas I C.
I
fj 0,li g
4 2 co
r..T. w ST OF NEW YORK.
BURIAL PERM IT.
Form 5M
A_T-_,E,
1 14
e
C4
U
Z
Z
0
:g .
'4 2 -I-.
{(vi•Illaagmee)°:0-dr°Cwonunty 1 '
et Oa..--1.--t,iI.4 ,a
(Dated,) 7 Z 7 19 i Y
The Certificate of Death having been furnished to me, as required y the Laws of this State,
1 c.).v-.' as permission is hereby given for the Burial of....,14----a/2.' ATO",
.. ... sm-
.,
Sex,"C--4. Age .7 7 A who died at (City or Townshi
. , in the
11.1 41 O.r:1 c"11 County of a/r--ate-2 -A.4-- , on ‘-44-/fg-s4-4.--t Z.v 19/1e..,'the cause 4.3, ...
..., ..
fr Place of Burial..*174
o .:1 r..--e, .4-'E of death being 24.../t.,4 .402- 4............... twan"...fat
-
i\i
Undertaker or person A.,44,zcz, y ..90,-,..._ (Sicned by)
..
charge of Bic ial, ..g. .4.1 4.'ti ite0t -
.Residence (OVER) (Official Title)
I 9*
•
•
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 19
Signed _________
Filed -19
Registrar of the
of N. Y.
NOTE—"ibis Permit is only to be issued for a Burial within the County where
t e 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 disvnsed of on th'orornises 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
CHASE. HOUGHTALING,
LAW BLANK PUBLISHER,
AIRARY Al v