Phelps, Adelia I _ .
Form 5%
4:11i ill STATE or NEW TORE.
BURIAL.. PERM IT.
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* U . 6'-' ,,, .2 The Certificate of Death having been furnished to me, as required by the Laws of this Slate,
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,...,,..0 ,.. fiermission is hereby given for the Burial of
: Z 4 1 -6. 2 (City or T9.1vjf,nalhiD)
Sex 14414-.4.4,:._ Age /2,44., who died at__ t-
aA- r--e- --1.-1,14, , in the
g .ra....
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al—
14 .19 2'n e2 County of_12k(---1--_1 --
on C9c-74- 7 " — 19 77; the cause
0 1 :Zi ii 4 s. :E.- of death beingeal-tp.--1--t_,_"al 0/2(7,L4' Place of Burial ai-v-....0_ -,......j.,Z '*•-'1 RtLi rs
Undertaker or person t44.1.44,7,"... ir,_5: ,,__ (Signed by) 4-79'
....- in charge of Burial, f -- --------------------
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,ovER,,
(Official Title)
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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—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 dicnosed 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 SOLD BY
CHAS.E. HOUGHTALING,
LAW BLANK PUBLISHER,
ALBANY, N. Y.