Murray, Sarah Form vs.er. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Penult can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH. LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._,Q. ..
-/C/Coup _-
Village
,/C�
Dist. No F? ty..�.11r ��-�. �`7/ or City � ����
/a ''-`V'C.` c `�7_ (IL city, give street t address)
Name of deceased �// /i'///� Veteran ` -
Sin le, married, widorved� (If ..� an. aive name of wv)
'�
Sex olor r rvorced (write the ward)......iJ� G Date of Death V 19.17X
Age , - Years: S Months.. ..f..�...._...Da Birthplace iS' . dry }..'1.:..1....,
Cause of Death (-ems Y 2j ' ,,," , .ate•
p
Certificate was signed by (, , .., . er.r M.D.
Address - - 17,.,
Place of Burial or Removal) L... �, ( `' y, , ..�... - y.
(Ii body I.to be p arily heldy li�lt in apace late U
Cemetery , l,l...c,A�c�f' Date of Burial 2 b 19 S``f
(If body is to be temporarily held,All in space later)
Tht;Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basis I HEREBY GRANT A PERMIT
xa > (Address)
the .�: .. .� -er to hold temporarily and the body.
(Unde or person hating charge of corpse) (In re ote, otherwise loose of(state how)) y
Dated , - ,.Z s 19..,•5.-Y (Signed) j Q .
... Local egtsirar
This Permit is sufficient for the Removal (and Interment ter Cremation) of a body to any peat of the State (subject to local
:emetery or other regulations),unless removal is by common curvier, in which case a Transit Permit (VS No. 62) is required.
.a+ art•• as ya- .J is .41A1 v.d�. 1c..t.�.W'-Fst gal ai a 4 cafa.v,.c s:i a.
REP�IISES ON ICH 1 T&IZMEsNTS OR -
- ., `C 2EMA`i'I NS AR M E'
Date -I--; avas4 _19 r
,,� t n.41/44 xren�t'';o )-,� ' . ' , 4.:
r ,r G ' f Name of Ceteter ematorium j �� ., .,
� 7" ` = 12 N .,
Section .,a' N e <tr1ve Nib'
(Signed'' .. � • `
Perscih3Echarile must return this Permit to Regrstitar of,his Diiarrict wain
SEVEN. O DA S from above date:`.;,If`n rson is in ,charge, the UNDER
TAKER MOST SIGN ABOVE STATE T. write across the face of th
Permit 0i: ,„words; "No person:in charge,'"and. FILE PERMIT WITI-nIN
HIR,E J DAYS withtRegistrar of:District it ;which cemetery is:located, %
`, E*RAFTS 'THE VITA.?STATISTICS LA 4'
9 tr$75' ''�rmits for burial fir removal of dead b ie3--•,the,�body of any,per;"Ali
"• to�s,.4 &ea' "s ccuri in this state.or which shy 1 be.found dead thereifr shall not
g inscri v r.4,eposited in;a rvaa lt:ior•tomb,`cremated or,,thL rwise dis sec ofe er
l traared or into any regis -ation district, or bet;tempo arily he pendi
further cis o ition more:than'sevenfy two:hours after death nless a ermif
brfrili r al,or other iiisposition thereof shall have$eemp perly issued by= e
regist'Iar'o pital statistics al the registration district tfi wht b,"'the death occurre)
oV t bgii szas foynd. ]Skis itch burial or removal pe i shall be i y'ued by XI
y
�rs&rar, , wherever; i aeticalble, a: complete•an c satipietor:y .reertifrcat
tht,hat filed with.hhnas herto#ore provided t 4ttWi)enica. de$`d bec
is tra7 spfi d fromioutside of hshstate intp a registra{-tta , flict'in.(his Oategar
Dial_ th', ansit or removal pere/tit issnediin accorda tFthe law and helll
aeg, �ioaseof the place where the death occurred shah en•th saele f
., /0h . o, . .
veil ,�ee� btyrrai permit herein:provided for.: No-,scglstttgr of 1 stati
s, all'r•ecery wt\.f e for the issuance of:burial or removal'hermits utMgr--
c tier that► $ ri ensation provided in this article. Pros how er, that litir
,s��� oe 7messio E-of health shall have power.to Aron atte`Miles vi #t refergitcce
to.:he rah al o bodies of persons whose deaths occur' n ns bits or•o
o ri son god in the transportation of personsrroyith t phis ate. t- u 1,
'rl§., 79z uties of undertaker. In:each case the uric rt e+i or person hav n
darke ofnthe corpse, shall file the_,certificate of:dearth t it$t!• •tte, r o a registraf the.di
,4 tiriet r h the death occurred and obtain a burial Koval pern t priori th
any t pq� ion of the body. * * Tire undertaker shalli,ieliver the burial perinit
t he-.eyes in charge of;the pla�of burial,befo interrnii or otherw,iie ilispPs-
ini s the ody; or shall atta h',he:removal:per*»t 1ta.lte box:containing 1'he
z;
corp,t shipp$d-by any tra�portatiolr cbmp"�ny,�sa'3d-�ppermit to a2cclmp�r►�r
the p its destination, Where if within the stag?pf-New York, it slf�llll,.h
dig • d air the pers¢i•i4t charge Of the place of burial : . r"'
'§�,d$1,..,rtermer{tL 11‘lo person in charge of dny-ptenruses on which infer'=
ni*Woraktkmations ltre�lnade'.shaal iptel- of permit th fintermentiar of er dis`ot
)tfpn"�f air53 lady unless t is 2Qcofnpanied by a bunal prethation o r • it permits
erein-Ro iled. Such persoir shall endorse:upon tire erfnit, theidat ofinteer,:
t, or c �aQion e r his.signature., and $hail recur rmits �'o a dm oe 10
the registt * his district--"„witbin:seyeni days front th t of interniept or lee
mation. Helstall keeil a ieatord of all bodies interred q ntlkerwise disp8sed o on
the prem7s"b Ender:Its charge; in each;cane stating t c fraine of each dece
person, p e-nf dear date of:burial of disposal, and-n m and:address:of e
undertaker;-,wwich record ball at all times be open to 4-111:p4 inspdctionn ptovi ed
that the iirf ler.taker or pert n having charge of the co e, when burying a bill
in a cem ty or burial grand having flo person in ct L'k shall:sign She bun
or removal perniit, giving:t6e date:of burial;and shall•wwr cross the:flsce of Vie
permit thevosds "No person in charge," and file'the burl or r'en;Oval perrff_iirr
within three.days with the registrar of the district in wh ii.t*cemete is locate
SEXTONS and UNDERTAKERS violating the``l'aw relatiw`�e to the return of per-
mits are liable to a penalty of NOT LESS THAN FIVE PC LABS NOR MORE
THAN FIFTY DOLLARS:FOR:THE FIRST OFFENSE.-The law will'be enforced.
Local. Registrars. are reauired. under penalty. to renort violations thereof