Juvet, Ulysses A so
sa
•
. c STATE E OF NEW J W e Form S'a
•
" a«r E BURIAL. PERM IT.
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4 al E v b +_-'
•Ss (' 0°«c Name of Tewu l64 yLesal, ''
y ai .V.a (Village) and Connty
• t as
x o a` a (Dated,) - 2 19 I
p �U�j d s 2 The Certificate of Death having been furnished to me, as required by the Laws of this Slate,
♦ z ha A .
- d u r r permission is hereby given for the Burial of rti2-ail----a. „�L�-i-_t
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a cp-
a O^
C „.a° o _ / 7� (City or Towmhi
s Se jr(- Age ( __. who died at in the
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iCd
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Wfi� .g. = County of_ _ __��.e. ....=� ______ on Z d 19 ;the cause
0 ,. of death being - ...4..4...14, „s f ZZ._---place of Burial
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o=.4 °- Undertaker or person
0 w a ltet: - (Signed by) ">- — —
o , r a„ in charge of Burial,
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Q 1n n'a (4i1j Residence y . .re.,S- . 'sf �/ -'- (OVERT-1 (official Title)
I
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 ✓�i7
{ Cremation _ —_____19/y
Signed L.#d _p
Filed /4 70 19//'(
Registrar of the - —
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 otherwise dit',used of on the premixes 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,
ALBANY, N. Y.